Provider Demographics
NPI:1639888530
Name:ELEY, JAMAN ROBERT (SUDDC)
Entity Type:Individual
Prefix:
First Name:JAMAN
Middle Name:ROBERT
Last Name:ELEY
Suffix:
Gender:M
Credentials:SUDDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9592 PERIDOT AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92344-8099
Mailing Address - Country:US
Mailing Address - Phone:714-225-5994
Mailing Address - Fax:
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD # 1208
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4600
Practice Address - Country:US
Practice Address - Phone:714-299-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7078101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)