Provider Demographics
NPI:1346560935
Name:DAVIS, JEFFREY HAROLD
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:HAROLD
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 60TH ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2369
Mailing Address - Country:US
Mailing Address - Phone:510-835-5010
Mailing Address - Fax:
Practice Address - Street 1:954 60TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2369
Practice Address - Country:US
Practice Address - Phone:510-835-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0136Medicaid