Provider Demographics
NPI:1306964655
Name:JERVIK, KEVIN (PHD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:JERVIK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N HARBOR BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2200
Mailing Address - Country:US
Mailing Address - Phone:310-833-3696
Mailing Address - Fax:310-833-3572
Practice Address - Street 1:411 N HARBOR BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2200
Practice Address - Country:US
Practice Address - Phone:310-833-3696
Practice Address - Fax:310-833-3572
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19560103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent