Healthcare Provider Details

I. General information

NPI: 1497975882
Provider Name (Legal Business Name): SAN JOSE/EVERGREEN COMMUNITY COLLEGE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 YERBA BUENA RD
SAN JOSE CA
95135-1513
US

IV. Provider business mailing address

3095 YERBA BUENA RD
SAN JOSE CA
95135-1513
US

V. Phone/Fax

Practice location:
  • Phone: 408-270-6480
  • Fax: 408-532-1831
Mailing address:
  • Phone: 408-270-6480
  • Fax: 408-532-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License NumberEXE70004F
License Number StateCA

VIII. Authorized Official

Name: JANICE ASSADI
Title or Position: DIRECTOR OF STUDENT HEALTH SERVICES
Credential: RN
Phone: 408-274-7900