Healthcare Provider Details

I. General information

NPI: 1407038110
Provider Name (Legal Business Name): JUST KIDS LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 GOUGH ST
SAN FRANCISCO CA
94123-4405
US

IV. Provider business mailing address

2722 GOUGH ST
SAN FRANCISCO CA
94123-4405
US

V. Phone/Fax

Practice location:
  • Phone: 415-775-5511
  • Fax: 415-775-5521
Mailing address:
  • Phone: 415-775-5511
  • Fax: 415-775-5521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSP12079
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP12079
License Number StateCA

VIII. Authorized Official

Name: JENNIFER A LOPEZ
Title or Position: DIRECTOR
Credential: MS, CCC-SLP
Phone: 415-775-5511