Healthcare Provider Details

I. General information

NPI: 1518167154
Provider Name (Legal Business Name): JASON EDWARD SEALS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MYRTLE ST SUITE 102
OAKLAND CA
94607-2525
US

IV. Provider business mailing address

870 S 45TH ST APT 5
RICHMOND CA
94804-4454
US

V. Phone/Fax

Practice location:
  • Phone: 510-663-3880
  • Fax:
Mailing address:
  • Phone: 510-277-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF62214
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: