Provider Demographics
NPI:1831396621
Name:ECLEVIA, JO
Entity type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:ECLEVIA
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 1:488 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-5267
Mailing Address - Country:US
Mailing Address - Phone:408-821-7454
Mailing Address - Fax:
Practice Address - Street 1:484 E SAN FERNANDO ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-3513
Practice Address - Country:US
Practice Address - Phone:408-293-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALMFT108219106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA109121OtherSAN JOSE CITY EMPLOYEE ID