Healthcare Provider Details

I. General information

NPI: 1942161450
Provider Name (Legal Business Name): STACEY KOJAKU
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5212 KATELLA AVE STE 103B
LOS ALAMITOS CA
90720-6828
US

IV. Provider business mailing address

PO BOX 8712
NEWPORT BEACH CA
92658-8712
US

V. Phone/Fax

Practice location:
  • Phone: 949-257-2423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: