=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932255577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JOAQUIN COUNTY OFFICE OF EDUCATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 08/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2707 TRANSWORLD DR
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95206-3948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-468-4960
-----------------------------------------------------
Fax | 209-468-4955
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 213030 2901 ARCH-AIRPORT ROAD
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95213-9030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-468-4960
-----------------------------------------------------
Fax | 209-468-4955
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SAN JOAQUIN COUNTY SUPERINTENDENT O
-----------------------------------------------------
Name | DR. MICK WILLIAM FOUNTS
-----------------------------------------------------
Credential | ED.D.
-----------------------------------------------------
Telephone | 209-468-4802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number | SS3910397
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------