Healthcare Provider Details

I. General information

NPI: 1124325691
Provider Name (Legal Business Name): JESSICA SONG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 02/18/2011
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

1513 LA TERRACE CIR
SAN JOSE CA
95123-5348
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-2321
  • Fax: 408-885-5822
Mailing address:
  • Phone: 408-960-4798
  • Fax: 408-885-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number52295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: