Healthcare Provider Details

I. General information

NPI: 1811717556
Provider Name (Legal Business Name): JEREL JAY GAMBOL BORROMEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 9TH STREET
SAN FRANCISCO CA
94103
US

IV. Provider business mailing address

170 9TH ST
SAN FRANCISCO CA
94103-2603
US

V. Phone/Fax

Practice location:
  • Phone: 415-255-6544
  • Fax:
Mailing address:
  • Phone: 415-225-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: