Healthcare Provider Details

I. General information

NPI: 1871726109
Provider Name (Legal Business Name): JAY L ROBERTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2009
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E CANAL DR
TURLOCK CA
95380-3936
US

IV. Provider business mailing address

12155 CHAD LN
WATERFORD CA
95386-9400
US

V. Phone/Fax

Practice location:
  • Phone: 209-669-2583
  • Fax:
Mailing address:
  • Phone: 209-683-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number61017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: