Healthcare Provider Details

I. General information

NPI: 1093386542
Provider Name (Legal Business Name): JUANCHO MIGUEL SAN PEDRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAY SAN PEDRO

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BERN CT STE 130
SAN JOSE CA
95112-1242
US

IV. Provider business mailing address

911 BERN CT STE 130
SAN JOSE CA
95112-1242
US

V. Phone/Fax

Practice location:
  • Phone: 408-437-8864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: