Healthcare Provider Details

I. General information

NPI: 1376992867
Provider Name (Legal Business Name): JACQUELINE OLIVIA CHILDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE OLIVIA CHILDS

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 LLEWELLYN AVE
CAMPBELL CA
95008-1940
US

IV. Provider business mailing address

251 LLEWELLYN AVE
CAMPBELL CA
95008-1940
US

V. Phone/Fax

Practice location:
  • Phone: 408-379-3790
  • Fax:
Mailing address:
  • Phone: 408-379-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122336
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberF2928188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: