=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790566263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFFRON BEHAVIORAL HEALTH AND PSYCHOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2023
-----------------------------------------------------
Last Update Date | 03/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 COLUSA AVE
-----------------------------------------------------
City | EL CERRITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94530-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-913-2232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 COLUSA AVE
-----------------------------------------------------
City | EL CERRITO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94530-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JASEON OUTLAW
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 510-564-5955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------