Provider Demographics
NPI:1518167154
Name:SEALS, JASON EDWARD
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:SEALS
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 1:870 S 45TH ST APT 5
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-4454
Mailing Address - Country:US
Mailing Address - Phone:510-277-2008
Mailing Address - Fax:
Practice Address - Street 1:111 MYRTLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2525
Practice Address - Country:US
Practice Address - Phone:510-663-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAIMF62214106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program