Basic Information
| Provider Information | |||||||||
| NPI: | 1548749500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVANO | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2335 E KASHIAN LN STE 301 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594596394 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PSY30197 | CA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.