Healthcare Provider Details

I. General information

NPI: 1548183445
Provider Name (Legal Business Name): JASON MICHAEL POWERS SUDRC2
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 MURPHY WAY
MALIBU CA
90265-4490
US

IV. Provider business mailing address

817 COUNTRY CLUB DR APT 8
SIMI VALLEY CA
93065-6636
US

V. Phone/Fax

Practice location:
  • Phone: 424-479-4462
  • Fax:
Mailing address:
  • Phone: 661-313-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: