Healthcare Provider Details

I. General information

NPI: 1205493038
Provider Name (Legal Business Name): ALEXIS NICOLE KOJO I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 CAMINO DEL RIO S STE 201
SAN DIEGO CA
92108-3505
US

IV. Provider business mailing address

409 CAMINO DEL RIO S STE 201
SAN DIEGO CA
92108-3505
US

V. Phone/Fax

Practice location:
  • Phone: 619-346-4020
  • Fax:
Mailing address:
  • Phone: 619-346-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number133935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: