Provider Demographics
NPI:1699210310
Name:LAO, JENNIFER CUC XUAN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CUC XUAN
Last Name:LAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3521
Mailing Address - Country:US
Mailing Address - Phone:408-613-8767
Mailing Address - Fax:
Practice Address - Street 1:3028 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-3521
Practice Address - Country:US
Practice Address - Phone:408-613-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor