Healthcare Provider Details

I. General information

NPI: 1396679858
Provider Name (Legal Business Name): JERRY JULIAN JEROME PRIMM CADC I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16168 BEACH BLVD STE 100
HUNTINGTON BEACH CA
92647-3872
US

IV. Provider business mailing address

16168 BEACH BLVD STE 100
HUNTINGTON BEACH CA
92647-3872
US

V. Phone/Fax

Practice location:
  • Phone: 714-312-3099
  • Fax:
Mailing address:
  • Phone: 714-312-3099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAII053620326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: