Healthcare Provider Details

I. General information

NPI: 1770122178
Provider Name (Legal Business Name): JAYNE D HAGEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 MASONIC AVE
BERKELEY CA
94706-2329
US

IV. Provider business mailing address

1213 MASONIC AVE
BERKELEY CA
94706-2329
US

V. Phone/Fax

Practice location:
  • Phone: 510-778-4055
  • Fax:
Mailing address:
  • Phone: 510-778-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JAYNE D. HAGEN
Title or Position: OWNER
Credential: PHD
Phone: 510-778-4055