Healthcare Provider Details

I. General information

NPI: 1053941989
Provider Name (Legal Business Name): JLD ALL-STARS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 N WINCHESTER BLVD STE 2G
SAN JOSE CA
95128-1357
US

IV. Provider business mailing address

826 N WINCHESTER BLVD STE 2G
SAN JOSE CA
95128-1357
US

V. Phone/Fax

Practice location:
  • Phone: 408-337-2727
  • Fax: 408-478-4130
Mailing address:
  • Phone: 408-337-2727
  • Fax: 408-478-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L DAVIS
Title or Position: OWER/OPERATOR
Credential: MS, OTR/L
Phone: 408-337-2727