Provider Demographics
NPI:1942703715
Name:AJEX PALVANNAN, JERRICKSON DANIEL
Entity Type:Individual
Prefix:
First Name:JERRICKSON
Middle Name:DANIEL
Last Name:AJEX PALVANNAN
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:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-868-8080
Mailing Address - Fax:
Practice Address - Street 1:2151 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4113
Practice Address - Country:US
Practice Address - Phone:661-868-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-17
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127180106H00000X
CA11023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health