Provider Demographics
NPI:1689923179
Name:IACOCCA, JOSEPH ANGELO
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ANGELO
Last Name:IACOCCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 W. JULIAN STREET
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126
Mailing Address - Country:US
Mailing Address - Phone:408-292-9353
Mailing Address - Fax:408-288-6201
Practice Address - Street 1:950 W. JULIAN STREET
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126
Practice Address - Country:US
Practice Address - Phone:408-292-9353
Practice Address - Fax:408-288-6201
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALNR 21606101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)