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General NPI Number Information
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NPI Number | 1861747552
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Entity Type | Individual
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Provider Name | JASEON S. OUTLAW PHD
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Gender | Male
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Dates
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Enumeration Date | 07/18/2012
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Last Update Date | 03/29/2016
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Provider Practice Location Address
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Address Line | 13847 E 14TH ST STE 202
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City | SAN LEANDRO
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State | CA
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Zip | 94578-2626
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Country | US
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Telephone | 510-463-1302
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Fax |
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Provider Business Mailing Address
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Address Line | 13847 E 14TH ST STE 202
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City | SAN LEANDRO
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State | CA
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Zip | 94578-2626
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Country | US
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Telephone | 510-463-1302
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY23676
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License Number State | CA
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