Provider Demographics
NPI:1326506221
Name:BASHEM, JESSE RYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:RYAN
Last Name:BASHEM
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:PO BOX 194
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93020-0194
Mailing Address - Country:US
Mailing Address - Phone:949-899-2301
Mailing Address - Fax:
Practice Address - Street 1:4000 MACARTHUR BLVD STE 600
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2517
Practice Address - Country:US
Practice Address - Phone:949-899-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-09
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30607103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical