Healthcare Provider Details

I. General information

NPI: 1174045017
Provider Name (Legal Business Name): JINGYUAN LIAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 COOLIDGE AVE
OAKLAND CA
94602-3311
US

IV. Provider business mailing address

317 LESTER AVE # 407
OAKLAND CA
94606-1316
US

V. Phone/Fax

Practice location:
  • Phone: 510-482-2244
  • Fax:
Mailing address:
  • Phone: 909-296-0049
  • Fax: 909-296-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number91887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number135047
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: