Healthcare Provider Details

I. General information

NPI: 1114853249
Provider Name (Legal Business Name): JOSE MANUEL AVILA ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 BROOK HOLLOW CIR
STOCKTON CA
95219-2436
US

IV. Provider business mailing address

6480 BROOK HOLLOW CIR
STOCKTON CA
95219-2436
US

V. Phone/Fax

Practice location:
  • Phone: 209-470-2953
  • Fax:
Mailing address:
  • Phone: 209-470-2953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: