Healthcare Provider Details

I. General information

NPI: 1689812364
Provider Name (Legal Business Name): JERRY A BORISKIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MUIR RD
MARTINEZ CA
94553-4668
US

IV. Provider business mailing address

150 MUIR ROAD
MARTINEZ CA
94553
US

V. Phone/Fax

Practice location:
  • Phone: 561-703-6106
  • Fax:
Mailing address:
  • Phone: 561-703-6106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPY0003779
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0003779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: