Provider Demographics
NPI:1700267721
Name:THAO, JAI
Entity Type:Individual
Prefix:
First Name:JAI
Middle Name:
Last Name:THAO
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 1:40910 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4375
Mailing Address - Country:US
Mailing Address - Phone:510-770-8040
Mailing Address - Fax:
Practice Address - Street 1:3200 SENTER RD RM S-105
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1332
Practice Address - Country:US
Practice Address - Phone:408-347-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103T00000X
CAPSB94024755101YM0800X
CA103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health