Healthcare Provider Details

I. General information

NPI: 1629596846
Provider Name (Legal Business Name): SKYLER JACK JAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRIANNA CHRISTINE JAYNE

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 MERCURY WAY STE 107
SANTA ROSA CA
95407-5472
US

IV. Provider business mailing address

201 ALAMEDA DEL PRADO STE 103
NOVATO CA
94949-6698
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-8452
  • Fax:
Mailing address:
  • Phone: 415-457-6964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: