Basic Information
| Provider Information | |||||||||
| NPI: | 1710215231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTINO | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 GRANADA AVE | ||||||||
| Address2: | #129 | ||||||||
| City: | SANTA CLARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950513300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055518353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | 4082549960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
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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 | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | MFC54001 | 01 | CA | LMFT | OTHER |