Provider Demographics
NPI:1821024845
Name:MYSTKOWSKI, JAYSON L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:L
Last Name:MYSTKOWSKI
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 1:5757 WILSHIRE BLVD STE 439
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3628
Mailing Address - Country:US
Mailing Address - Phone:310-579-9335
Mailing Address - Fax:310-579-9335
Practice Address - Street 1:5757 WILSHIRE BLVD STE 439
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3628
Practice Address - Country:US
Practice Address - Phone:310-579-9335
Practice Address - Fax:310-579-9335
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP20077Medicare ID - Type Unspecified