Provider Demographics
NPI:1962824052
Name:JOURNEY OF LIFE COUNSELING AND ASSESSMENT SERVICES
Entity Type:Organization
Organization Name:JOURNEY OF LIFE COUNSELING AND ASSESSMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASEON
Authorized Official - Middle Name:
Authorized Official - Last Name:OUTLAW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:510-463-1302
Mailing Address - Street 1:1068 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3731
Mailing Address - Country:US
Mailing Address - Phone:510-463-1302
Mailing Address - Fax:
Practice Address - Street 1:1068 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-3731
Practice Address - Country:US
Practice Address - Phone:510-463-1302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23676103TC0700X
CA53851106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty