Provider Demographics
NPI:1245878560
Name:GAJANO-BLYTHE, JANE (LAC)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:GAJANO-BLYTHE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 COLUSA AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:94707-1209
Mailing Address - Country:US
Mailing Address - Phone:510-863-0333
Mailing Address - Fax:510-898-1279
Practice Address - Street 1:806 NORTHVALE RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2407
Practice Address - Country:US
Practice Address - Phone:415-699-6017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
CA18734171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty