Provider Demographics
NPI:1760633523
Name:DEBRUIN, JODY EDWIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:EDWIN
Last Name:DEBRUIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOE
Other - Middle Name:EDWIN
Other - Last Name:DEBRUIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1600 9TH ST
Mailing Address - Street 2:ROOM 150 FISCAL ALLOCATIONS AND ESTIMATES UNIT
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-651-9475
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:10333 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5808
Practice Address - Country:US
Practice Address - Phone:805-468-2000
Practice Address - Fax:805-468-6011
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21895103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical