Healthcare Provider Details

I. General information

NPI: 1649632480
Provider Name (Legal Business Name): JASMINE MENDOZA BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 SARATOGA AVE STE 100
SAN JOSE CA
95129-4965
US

IV. Provider business mailing address

PO BOX 767938
ROSWELL GA
30076-7938
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-6780
  • Fax: 818-241-6853
Mailing address:
  • Phone: 818-241-6780
  • Fax: 818-241-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-40636
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: