Healthcare Provider Details

I. General information

NPI: 1699118695
Provider Name (Legal Business Name): JAY WARREN MALISPINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000A, 1010C EMELINE AVE.
SANTA CRUZ CA
95060-1900
US

IV. Provider business mailing address

1000A, 1010C EMELINE AVE.
SANTA CRUZ CA
95060-1900
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-0112
  • Fax: 831-425-1847
Mailing address:
  • Phone: 831-425-0112
  • Fax: 831-425-1847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: