Healthcare Provider Details

I. General information

NPI: 1366562332
Provider Name (Legal Business Name): JASON STUART SCHILDHAUS M.F.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12520 HIGH BLUFF DR SUITE 120
SAN DIEGO CA
92130-2041
US

IV. Provider business mailing address

3617 BERNWOOD PL APT 102
SAN DIEGO CA
92130-1046
US

V. Phone/Fax

Practice location:
  • Phone: 858-259-0599
  • Fax: 858-794-7218
Mailing address:
  • Phone: 858-755-3938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFT19749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: