Healthcare Provider Details

I. General information

NPI: 1114658366
Provider Name (Legal Business Name): DUDLEY JAY WIEST PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 E CHAPMAN AVE STE 202
ORANGE CA
92866-2139
US

IV. Provider business mailing address

3345 E COPPER KETTLE WAY
ORANGE CA
92867-2057
US

V. Phone/Fax

Practice location:
  • Phone: 714-744-9754
  • Fax:
Mailing address:
  • Phone: 714-273-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number14883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: