Healthcare Provider Details

I. General information

NPI: 1992038681
Provider Name (Legal Business Name): JORIN BUKOSKY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 WILLOW RD (321 / C-128)
MENLO PARK CA
94025
US

IV. Provider business mailing address

795 WILLOW RD (321 / C-128)
MENLO PARK CA
94025
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax:
Mailing address:
  • Phone: 650-493-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number86083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: