Provider Demographics
NPI:1316131063
Name:JERVIS, JOHN ELLIOTT
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ELLIOTT
Last Name:JERVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:ELLIOTT
Other - Last Name:JERVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4363 MAHOGANY LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-6081
Mailing Address - Country:US
Mailing Address - Phone:530-219-5117
Mailing Address - Fax:
Practice Address - Street 1:140 B ST STE 6G
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4589
Practice Address - Country:US
Practice Address - Phone:530-219-5117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39484106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist