| Journey Of Life Psychological, Inc. | |
|
13847 E 14th St Ste 202 San Leandro CA 94578-2626 | |
| (510) 564-5955 | |
| (510) 817-4112 |
| Full Name | Journey Of Life Psychological, Inc. |
|---|---|
| Speciality | Clinic/Center |
| Location | 13847 E 14th St Ste 202, San Leandro, California |
| Authorized Official Name and Position | Jaseon Outlaw (CEO) |
| Authorized Official Contact | 5104631302 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Journey Of Life Psychological, Inc. 13847 E 14th St Ste 202 San Leandro CA 94578-2626 Ph: (510) 564-5955 | Journey Of Life Psychological, Inc. 13847 E 14th St Ste 202 San Leandro CA 94578-2626 Ph: (510) 564-5955 |
| NPI Number | 1073122958 |
|---|---|
| Provider Enumeration Date | 07/28/2020 |
| Last Update Date | 07/28/2020 |
| Certification Date | 07/28/2020 |
| Medicare PECOS PAC ID | 7214339423 |
|---|---|
| Medicare Enrollment ID | O20210712000326 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073122958 | NPI | - | NPPES |
| CA228465 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Jaseon Outlaw |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1861747552 PECOS PAC ID: 0749560449 Enrollment ID: I20161215002226 |
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