Provider Demographics
NPI:1477729143
Name:FORTMAN, JAY (PHD, MFT)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:FORTMAN
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5276 HOLLISTER AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-2071
Mailing Address - Country:US
Mailing Address - Phone:805-967-2166
Mailing Address - Fax:
Practice Address - Street 1:5276 HOLLISTER AVE STE 301
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-2071
Practice Address - Country:US
Practice Address - Phone:805-967-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT19427106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist