Healthcare Provider Details

I. General information

NPI: 1356753420
Provider Name (Legal Business Name): JEANETTE LAAKSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 GLENN
IRVINE CA
92620-3352
US

IV. Provider business mailing address

34 GLENN
IRVINE CA
92620-3352
US

V. Phone/Fax

Practice location:
  • Phone: 949-939-3278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP26325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: