Provider Demographics
NPI:1215102264
Name:PHELPS, JEROLD SCOTT (PHD)
Entity type:Individual
Prefix:
First Name:JEROLD
Middle Name:SCOTT
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:9500 GILMAN DRIVE 0304
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0304
Mailing Address - Country:US
Mailing Address - Phone:858-822-2614
Mailing Address - Fax:858-534-2628
Practice Address - Street 1:9500 GILMAN DRIVE 0304
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0304
Practice Address - Country:US
Practice Address - Phone:858-822-2614
Practice Address - Fax:858-534-2628
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15347103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical