Provider Demographics
NPI:1760041156
Name:PAWID, JESSE DAVIDSON KOA
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DAVIDSON KOA
Last Name:PAWID
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 1:402 PALMER AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4391
Mailing Address - Country:US
Mailing Address - Phone:510-846-7987
Mailing Address - Fax:
Practice Address - Street 1:101 H ST STE L
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5100
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician