Provider Demographics
NPI:1295193720
Name:OWENS VALLEY WELLNESS
Entity Type:Organization
Organization Name:OWENS VALLEY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:760-920-6210
Mailing Address - Street 1:686 W LINE ST
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-3315
Mailing Address - Country:US
Mailing Address - Phone:760-920-6210
Mailing Address - Fax:
Practice Address - Street 1:686 W LINE ST
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-3315
Practice Address - Country:US
Practice Address - Phone:760-920-6210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty