Healthcare Provider Details

I. General information

NPI: 1770632515
Provider Name (Legal Business Name): JAY E EARLES PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CHESTERFIELD ST N
AIKEN SC
29801-3934
US

IV. Provider business mailing address

179 BLAIR DR
NORTH AUGUSTA SC
29860-9785
US

V. Phone/Fax

Practice location:
  • Phone: 803-641-9979
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number773
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number1469
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: