Healthcare Provider Details

I. General information

NPI: 1649468695
Provider Name (Legal Business Name): JACQUELINE PUTSOPHEAK FERNANDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE PUTSOPHEAK TAK

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 E CHAMPLAIN DR STE 101-710
FRESNO CA
93720-5033
US

IV. Provider business mailing address

1860 E BELLA ROSA AVE
FRESNO CA
93730-7026
US

V. Phone/Fax

Practice location:
  • Phone: 650-863-8325
  • Fax:
Mailing address:
  • Phone: 650-863-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW62661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: