Provider Demographics
NPI:1740838374
Name:KO, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:KO
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:PO BOX 2461
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95015-2461
Mailing Address - Country:US
Mailing Address - Phone:650-204-0466
Mailing Address - Fax:
Practice Address - Street 1:2635 ZANKER RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2107
Practice Address - Country:US
Practice Address - Phone:408-292-9353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8076101YP2500X
CA150385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional