Basic Information
Provider Information | |||||||||
NPI: | 1801437322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEDCALF | ||||||||
FirstName: | JAMISON | ||||||||
MiddleName: | BROGAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3426 ALDER CANYON WAY | ||||||||
Address2: |   | ||||||||
City: | ANTELOPE | ||||||||
State: | CA | ||||||||
PostalCode: | 958434989 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9162725665 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2901 S H ST | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933045602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6613984303 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2019 | ||||||||
LastUpdateDate: | 10/06/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | SUDRC10234 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | AMFT114404 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | SUDRC10234 | 01 | CA | CADTP | OTHER | AMFT114404 | 01 | CA | BOARD OF BEHAVIORAL SCIENCES | OTHER |