Basic Information
| Provider Information | |||||||||
| NPI: | 1376058958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DECARLO | ||||||||
| FirstName: | JACLYN | ||||||||
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| Credential: | RADT-I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 875 CINNABAR ST APT 2214 | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951262782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085094346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 102 S 11TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951122132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089985191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 12/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1244250217 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.