Provider Demographics
NPI:1528572500
Name:WASHBURN, JERRY WALKER
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WALKER
Last Name:WASHBURN
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 1:600 B ST STE 1570
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4560
Mailing Address - Country:US
Mailing Address - Phone:619-615-0439
Mailing Address - Fax:
Practice Address - Street 1:3853 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-615-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95083117163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult