Healthcare Provider Details

I. General information

NPI: 1942703715
Provider Name (Legal Business Name): JERRICKSON DANIEL AJEX PALVANNAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2018
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S H ST
BAKERSFIELD CA
93304-3930
US

IV. Provider business mailing address

PO BOX 3483
BAKERSFIELD CA
93385-3483
US

V. Phone/Fax

Practice location:
  • Phone: 661-364-6419
  • Fax:
Mailing address:
  • Phone: 661-364-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC19831
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT127180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: