Healthcare Provider Details

I. General information

NPI: 1194641464
Provider Name (Legal Business Name): JEROME DEVASE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8842 WINDING WAY APT 446
FAIR OAKS CA
95628-6498
US

IV. Provider business mailing address

8842 WINDING WAY APT 446
FAIR OAKS CA
95628-6498
US

V. Phone/Fax

Practice location:
  • Phone: 310-739-6575
  • Fax:
Mailing address:
  • Phone: 310-739-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4869157040
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2702085
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number260075400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: