Healthcare Provider Details

I. General information

NPI: 1447004635
Provider Name (Legal Business Name): JASON IAN WHITE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 CALIFORNIA ST APT D
MOUNTAIN VIEW CA
94041-1865
US

IV. Provider business mailing address

1475 CALIFORNIA ST APT D
MOUNTAIN VIEW CA
94041-1865
US

V. Phone/Fax

Practice location:
  • Phone: 760-468-3388
  • Fax:
Mailing address:
  • Phone: 760-468-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15229
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: