Provider Demographics
NPI:1154611465
Name:NEWMAN, JASON CORY
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CORY
Last Name:NEWMAN
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 1:1400 TECHNOLOGY LN APT 524
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6922
Mailing Address - Country:US
Mailing Address - Phone:707-782-8933
Mailing Address - Fax:
Practice Address - Street 1:680 WILSON AVE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3825
Practice Address - Country:US
Practice Address - Phone:707-742-3604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100091106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44AVOtherFS RES MHSS
CA44AVOtherFS RES MHSS