Provider Demographics
NPI:1366413064
Name:PAULO, JERROD D (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:JERROD
Middle Name:D
Last Name:PAULO
Suffix:
Gender:M
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13690 E 14TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2582
Mailing Address - Country:US
Mailing Address - Phone:510-895-5511
Mailing Address - Fax:510-895-5513
Practice Address - Street 1:13690 E 14TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2582
Practice Address - Country:US
Practice Address - Phone:510-895-5511
Practice Address - Fax:510-895-5513
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 2258225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31058ZOtherPROVIDER TRANSACTION ACCESS NUMBER
CAZZZ04670ZOtherBLUESHIELD PROVIDER #
CAZZZ04670ZOtherBLUESHIELD PROVIDER #