Healthcare Provider Details

I. General information

NPI: 1558124594
Provider Name (Legal Business Name): JACOB'S LADDER THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S BASCOM AVE STE 1014
SAN JOSE CA
95128-3537
US

IV. Provider business mailing address

950 S BASCOM AVE STE 1014
SAN JOSE CA
95128-3537
US

V. Phone/Fax

Practice location:
  • Phone: 408-471-4261
  • Fax: 408-608-3986
Mailing address:
  • Phone: 408-471-4261
  • Fax: 408-608-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TAMETRA JOHNSON
Title or Position: CEO
Credential: LCSW
Phone: 408-471-4261