Provider Demographics
NPI:1871726109
Name:ROBERTS, JAY L
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:ROBERTS
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 1:12155 CHAD LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95386-9400
Mailing Address - Country:US
Mailing Address - Phone:209-683-9026
Mailing Address - Fax:
Practice Address - Street 1:440 E CANAL DR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95380-3936
Practice Address - Country:US
Practice Address - Phone:209-669-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-03
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61017101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional