Provider Demographics
NPI:1821726084
Name:EGUSA, JERRY R (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:R
Last Name:EGUSA
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:P.O. BOX 6273
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94540
Mailing Address - Country:US
Mailing Address - Phone:510-733-6895
Mailing Address - Fax:510-733-6895
Practice Address - Street 1:10114 B STREET
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94540
Practice Address - Country:US
Practice Address - Phone:510-733-6895
Practice Address - Fax:510-733-6895
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18324103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist