Healthcare Provider Details

I. General information

NPI: 1629602958
Provider Name (Legal Business Name): JERRY GLADNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12141 BROOKHURST ST
GARDEN GROVE CA
92840-2865
US

IV. Provider business mailing address

12141 BROOKHURST ST
GARDEN GROVE CA
92840-2865
US

V. Phone/Fax

Practice location:
  • Phone: 714-296-1934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: