Basic Information
| Provider Information | |||||||||
| NPI: | 1154611465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEWMAN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | CORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 TECHNOLOGY LN APT 518 | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949546922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077741258 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2751 NAPA VALLEY CORPORATE DR BLDG A | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072534279 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 100091 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 44AV | 01 | CA | FS RES MHSS | OTHER |