Basic Information
| Provider Information | |||||||||
| NPI: | 1215102264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | JEROLD | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELPS | ||||||||
| OtherFirstName: | JERRY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9500 GILMAN DRIVE 0304 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588222614 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 GILMAN DRIVE 0304 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920930304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8588222614 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY15347 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PSY15347 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.