Healthcare Provider Details

I. General information

NPI: 1891959540
Provider Name (Legal Business Name): MRS. JEAN L. KNOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

982 BOUGAINVILLEA ST
SAN LUIS OBISPO CA
93401-7624
US

V. Phone/Fax

Practice location:
  • Phone: 805-788-2932
  • Fax:
Mailing address:
  • Phone: 805-544-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: