Basic Information
| Provider Information | |||||||||
| NPI: | 1619641347 | ||||||||
| 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: | 1149 E JULIAN ST BLDG H | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951161005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085356001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2021 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | JOCELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4082842289 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | HAP70689G | 01 | CA | MEDI-CAL | OTHER | FHC71018F | 01 | CA | MEDI-CAL ID | OTHER |