Provider Demographics
NPI:1073122958
Name:JOURNEY OF LIFE PSYCHOLOGICAL, INC.
Entity Type:Organization
Organization Name:JOURNEY OF LIFE PSYCHOLOGICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASEON
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:510-463-1302
Mailing Address - Street 1:13847 E 14TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2626
Mailing Address - Country:US
Mailing Address - Phone:510-564-5955
Mailing Address - Fax:510-817-4112
Practice Address - Street 1:13847 E 14TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2626
Practice Address - Country:US
Practice Address - Phone:510-564-5955
Practice Address - Fax:510-817-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA228465Medicaid