Provider Demographics
NPI:1205493038
Name:KOJO, ALEXIS NICOLE I
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:KOJO
Suffix:I
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 1:409 CAMINO DEL RIO S STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3505
Mailing Address - Country:US
Mailing Address - Phone:619-346-4020
Mailing Address - Fax:
Practice Address - Street 1:409 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3505
Practice Address - Country:US
Practice Address - Phone:619-346-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 175T00000X
CA172V00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALLTFF1095588OtherBLUECROSS