Healthcare Provider Details

I. General information

NPI: 1962824052
Provider Name (Legal Business Name): JOURNEY OF LIFE COUNSELING AND ASSESSMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 E 14TH ST
SAN LEANDRO CA
94577-3731
US

IV. Provider business mailing address

1068 E 14TH ST
SAN LEANDRO CA
94577-3731
US

V. Phone/Fax

Practice location:
  • Phone: 510-463-1302
  • Fax:
Mailing address:
  • Phone: 510-463-1302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23676
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53851
License Number StateCA

VIII. Authorized Official

Name: DR. JASEON OUTLAW
Title or Position: CLINICAL DIRECTOR/OWNER
Credential: PH.D.
Phone: 510-463-1302