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NPI Code Detail

MEDICARE: JACK PAUL TALLY

MEDICARE: JACK PAUL TALLY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) CounselorA052360521CA

General Provider Information

NPI Number : 1790256527
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACK PAUL TALLY
Provider Business Mailing Address
First Line : 1530 DALE ST
Second Line :
City : SAN DIEGO
State : CA
Zip : 92102-1519
Country : US
Telephone Number : 619-915-5710
Fax Number :
Provider Business Practice Location Address
First Line : 1530 DALE ST
Second Line :
City : SAN DIEGO
State : CA
Zip : 92102-1519
Country : US
Telephone Number : 619-915-5710
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/05/2018
Last Update Date : 03/26/2026

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Directions to “ JACK PAUL TALLY ” Practice Location

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