Provider Demographics
NPI:1104072610
Name:GATTIS, JAY (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:GATTIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 BRISTOL ST
Mailing Address - Street 2:STE A108
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5981
Mailing Address - Country:US
Mailing Address - Phone:714-432-0042
Mailing Address - Fax:714-432-0049
Practice Address - Street 1:2900 BRISTOL ST
Practice Address - Street 2:STE A108
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5981
Practice Address - Country:US
Practice Address - Phone:714-432-0042
Practice Address - Fax:714-432-0049
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19382103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical