Provider Demographics
NPI:1245348093
Name:REBERT, JAY (MFT)
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:
Last Name:REBERT
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8593 KERMES AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628
Mailing Address - Country:US
Mailing Address - Phone:916-241-9446
Mailing Address - Fax:
Practice Address - Street 1:11622 FAIR OAKS BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-241-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist