1629306907 NPI number — DR. JERRY ALBERT KASDORF PH.D.

Table of content: DR. JERRY ALBERT KASDORF PH.D. (NPI 1629306907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629306907 NPI number — DR. JERRY ALBERT KASDORF PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KASDORF
Provider First Name:
JERRY
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KASDORF
Provider Other First Name:
JERRY
Provider Other Middle Name:
ALBERT
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629306907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24511 WEST JAYNE AVENUE
Provider Second Line Business Mailing Address:
P O BOX 5002
Provider Business Mailing Address City Name:
COALINGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93210-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-935-7311
Provider Business Mailing Address Fax Number:
559-935-7271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24511 W JAYNE AVE
Provider Second Line Business Practice Location Address:
5002
Provider Business Practice Location Address City Name:
COALINGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93210-9503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-935-7311
Provider Business Practice Location Address Fax Number:
559-935-7271
Provider Enumeration Date:
11/25/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 4865 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)