Healthcare Provider Details

I. General information

NPI: 1982315511
Provider Name (Legal Business Name): KELSI JEROME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 S AMPHLETT BLVD STE 220
SAN MATEO CA
94402-2705
US

IV. Provider business mailing address

39899 BALENTINE DR STE 128
NEWARK CA
94560-5361
US

V. Phone/Fax

Practice location:
  • Phone: 650-762-4365
  • Fax:
Mailing address:
  • Phone: 650-931-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: