Healthcare Provider Details

I. General information

NPI: 1982569414
Provider Name (Legal Business Name): JAY GLENN SKELTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 NOVATO BLVD STE 210
NOVATO CA
94947-7855
US

IV. Provider business mailing address

1748 NOVATO BLVD STE 210
NOVATO CA
94947-7855
US

V. Phone/Fax

Practice location:
  • Phone: 415-209-4343
  • Fax:
Mailing address:
  • Phone: 415-209-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: