Healthcare Provider Details

I. General information

NPI: 1508186586
Provider Name (Legal Business Name): MS. JACLYN KELSEY BEDSOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 VINCENTE ST
SAN FRANCISCO CA
94116-2923
US

IV. Provider business mailing address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

V. Phone/Fax

Practice location:
  • Phone: 512-289-9639
  • Fax:
Mailing address:
  • Phone: 512-289-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: