Provider Demographics
NPI:1447246152
Name:ERICKSON, JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58342 UTE TRL
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-6176
Mailing Address - Country:US
Mailing Address - Phone:760-228-5865
Mailing Address - Fax:
Practice Address - Street 1:1458 4TH ST MCAGCC/ MAGTFTC
Practice Address - Street 2:7TH MARINE REGIMENTAL AID STATION
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-7876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine