Provider Demographics
NPI:1407514755
Name:MORRISSEY, JAMIE TAYLOR
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:TAYLOR
Last Name:MORRISSEY
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 1:2865 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2411
Mailing Address - Country:US
Mailing Address - Phone:619-232-4357
Mailing Address - Fax:
Practice Address - Street 1:2865 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2411
Practice Address - Country:US
Practice Address - Phone:619-232-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACERTIFICATE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty