Basic Information
| Provider Information | |||||||||
| NPI: | 1871726109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12155 CHAD LN | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953869400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096839026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 440 E CANAL DR | ||||||||
| Address2: | |||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953803936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096692583 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2009 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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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 | 101YP2500X | 61017 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.