Healthcare Provider Details

I. General information

NPI: 1639838295
Provider Name (Legal Business Name): JAQUELINE BILLIE JEPSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 JACKSON ST STE 4B
HAYWARD CA
94544-1556
US

IV. Provider business mailing address

384 JACKSON ST STE 4B
HAYWARD CA
94544-1556
US

V. Phone/Fax

Practice location:
  • Phone: 510-500-6769
  • Fax:
Mailing address:
  • Phone: 510-500-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: