Provider Demographics
NPI:1689812364
Name:BORISKIN, JERRY A (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:A
Last Name:BORISKIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUIR ROAD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553
Mailing Address - Country:US
Mailing Address - Phone:561-703-6106
Mailing Address - Fax:
Practice Address - Street 1:150 MUIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:561-703-6106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003779103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)