Healthcare Provider Details

I. General information

NPI: 1407978844
Provider Name (Legal Business Name): JERRY RAY PULLEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JERRAL RAY PULLEY LCSW

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28999 OLD TOWN FRONT ST STE. 105
TEMECULA CA
92590-5805
US

IV. Provider business mailing address

28999 OLD TOWN FRONT ST STE. 105
TEMECULA CA
92590-5805
US

V. Phone/Fax

Practice location:
  • Phone: 951-764-3245
  • Fax: 951-308-1515
Mailing address:
  • Phone: 951-764-3245
  • Fax: 951-308-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 17518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: