Provider Demographics
NPI:1124325691
Name:SONG, JESSICA (PHARMD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 LA TERRACE CIR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-5348
Mailing Address - Country:US
Mailing Address - Phone:408-960-4798
Mailing Address - Fax:408-885-5822
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-2321
Practice Address - Fax:408-885-5822
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA522951835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy