Healthcare Provider Details

I. General information

NPI: 1760092845
Provider Name (Legal Business Name): JINGYI QIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 CALAVERITAS RD
SAN ANDREAS CA
95249-9644
US

IV. Provider business mailing address

1337 CALAVERITAS RD
SAN ANDREAS CA
95249-9644
US

V. Phone/Fax

Practice location:
  • Phone: 650-484-6502
  • Fax:
Mailing address:
  • Phone: 650-484-6502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-76372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: