Healthcare Provider Details

I. General information

NPI: 1619016466
Provider Name (Legal Business Name): JESSICA KUO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2587 E WASHINGTON BLVD
PASADENA CA
91107-6205
US

IV. Provider business mailing address

260 S ARROYO DR A
SAN GABRIEL CA
91776-4368
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6753
  • Fax: 626-463-4145
Mailing address:
  • Phone: 626-497-0420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS26979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: