Provider Demographics
NPI:1689032419
Name:MIRANDA, JERMYN DOUGLAS
Entity Type:Individual
Prefix:
First Name:JERMYN
Middle Name:DOUGLAS
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JERMYNDOUGLAS
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1922 THE ALAMEDA STE 316
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1461
Mailing Address - Country:US
Mailing Address - Phone:408-261-7777
Mailing Address - Fax:408-642-6052
Practice Address - Street 1:1503 GRANT RD STE 110
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-3270
Practice Address - Country:US
Practice Address - Phone:650-484-1213
Practice Address - Fax:408-642-6052
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker