Provider Demographics
NPI:1699701250
Name:JARY, DONALD R (PHD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:JARY
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 1:700 E REDLANDS BLVD # U269
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6143
Mailing Address - Country:US
Mailing Address - Phone:858-205-5394
Mailing Address - Fax:
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:858-205-5394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12654103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY126542Medicaid
CAPSY126542Medicaid
CA680003627Medicare PIN
CA0PL126541Medicare PIN