Healthcare Provider Details

I. General information

NPI: 1730465048
Provider Name (Legal Business Name): JANE MARY DE GELLEKE SP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 ROYAL OAKS DR SUITE 200
SACRAMENTO CA
95815-3868
US

IV. Provider business mailing address

1901 ROYAL OAKS DR SUITE 200
SACRAMENTO CA
95815-3868
US

V. Phone/Fax

Practice location:
  • Phone: 916-923-1789
  • Fax: 916-923-1515
Mailing address:
  • Phone: 916-923-1789
  • Fax: 916-923-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: