Healthcare Provider Details

I. General information

NPI: 1689794976
Provider Name (Legal Business Name): JASON SALVADOR ROSALES LICENSED PSYCH TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

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

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

IV. Provider business mailing address

1233 SHADOW CREEK DR
STOCKTON CA
95209-1426
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-3760
  • Fax: 209-468-3779
Mailing address:
  • Phone: 209-468-3760
  • Fax: 209-468-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT29038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: