Provider Demographics
NPI:1972068146
Name:TALLEY, JAKE ALEXANDER
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:ALEXANDER
Last Name:TALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25402 PACIFICA AVE
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-3854
Mailing Address - Country:US
Mailing Address - Phone:949-238-2400
Mailing Address - Fax:
Practice Address - Street 1:25402 PACIFICA AVE
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-3854
Practice Address - Country:US
Practice Address - Phone:949-238-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician