Healthcare Provider Details

I. General information

NPI: 1801429360
Provider Name (Legal Business Name): JAISEN ALBOR AMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N CARPENTER RD STE B
MODESTO CA
95351-1185
US

IV. Provider business mailing address

1600 N CARPENTER RD STE B
MODESTO CA
95351-1185
US

V. Phone/Fax

Practice location:
  • Phone: 209-523-4573
  • Fax:
Mailing address:
  • Phone: 209-523-4573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT154355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: