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General NPI Number Information
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NPI Number | 1962824052
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Entity Type | Organization
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Legal Business Name | JOURNEY OF LIFE COUNSELING AND ASSESSMENT SERVICES
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Dates
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Enumeration Date | 01/09/2014
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Last Update Date | 01/09/2014
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Provider Practice Location Address
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Address Line | 1068 E 14TH ST
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City | SAN LEANDRO
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State | CA
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Zip | 94577-3731
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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 | 1068 E 14TH ST
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City | SAN LEANDRO
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State | CA
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Zip | 94577-3731
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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 | CLINICAL DIRECTOR/OWNER
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Name | DR. JASEON OUTLAW
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Credential | PH.D.
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Telephone | 510-463-1302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 53851
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License Number State | CA
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Taxonomy #2
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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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