Basic Information
Provider Information | |||||||||
NPI: | 1053085316 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCHOOL HEALTH CLINICS OF SANTA CLARA COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6840 VIA DEL ORO STE 210 | ||||||||
Address2: |   | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951191372 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4082842280 | ||||||||
FaxNumber: | 4087540450 | ||||||||
Practice Location | |||||||||
Address1: | 9300 WREN AVE | ||||||||
Address2: |   | ||||||||
City: | GILROY | ||||||||
State: | CA | ||||||||
PostalCode: | 950207636 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4088421017 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2021 | ||||||||
LastUpdateDate: | 02/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HART | ||||||||
AuthorizedOfficialFirstName: | JOCELYN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO/CFO | ||||||||
AuthorizedOfficialTelephone: | 4082842289 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 251X00000X |   |   | N |   | Agencies | Supports Brokerage |   | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC71038F | 01 | CA | MEDI-CAL ID | OTHER |