Healthcare Provider Details

I. General information

NPI: 1194334839
Provider Name (Legal Business Name): JASON SANDERS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 NORWALK DR APT CC207
SAN JOSE CA
95129-1708
US

IV. Provider business mailing address

PO BOX 399318
SAN FRANCISCO CA
94139-9318
US

V. Phone/Fax

Practice location:
  • Phone: 669-255-3129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number20-142130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: