Provider Demographics
NPI:1154462364
Name:JARVIS, ROBERT MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:JARVIS
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 1:151 KALMUS DR
Mailing Address - Street 2:SUITE B-220
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5988
Mailing Address - Country:US
Mailing Address - Phone:949-650-7025
Mailing Address - Fax:949-452-0889
Practice Address - Street 1:151 KALMUS DR
Practice Address - Street 2:SUITE B-220
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5988
Practice Address - Country:US
Practice Address - Phone:949-650-7025
Practice Address - Fax:949-452-0889
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPX0075850Medicaid
CAPX0075850Medicaid