Provider Demographics
NPI:1184383846
Name:SAGE, JACKLYN LOUISE
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:LOUISE
Last Name:SAGE
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 1:1400 ROLLINS RD STE B
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2315
Mailing Address - Country:US
Mailing Address - Phone:650-773-0100
Mailing Address - Fax:
Practice Address - Street 1:1400 ROLLINS RD STE B
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-2315
Practice Address - Country:US
Practice Address - Phone:650-340-1190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist