=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235928748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNELYN BACOSA
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2025
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 NEVIN AVE
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94801-3143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-307-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31537 HUGH WAY
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94544-7743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-787-1864
-----------------------------------------------------
Fax | 562-787-1864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 227900000X
-----------------------------------------------------
Taxonomy Name | Registered Respiratory Therapist
-----------------------------------------------------
License Number | 24664
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------