Healthcare Provider Details

I. General information

NPI: 1336567775
Provider Name (Legal Business Name): JACQUELINE FR LOU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

IV. Provider business mailing address

751 S BASCOM AVE
SAN JOSE CA
95128-2604
US

V. Phone/Fax

Practice location:
  • Phone: 510-859-4717
  • Fax:
Mailing address:
  • Phone: 510-859-4717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA138292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: