Provider Demographics
NPI:1023882727
Name:BOTT, JEFFERY RAY
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:RAY
Last Name:BOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3356 GULUZZO DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-1328
Mailing Address - Country:US
Mailing Address - Phone:510-418-2829
Mailing Address - Fax:
Practice Address - Street 1:298B BERNAL ROAD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119
Practice Address - Country:US
Practice Address - Phone:408-638-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-IRYJNS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist