Provider Demographics
NPI:1356406409
Name:SUMMERS, JAY D (PHD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:D
Last Name:SUMMERS
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:PO BOX 24076
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85285-4076
Mailing Address - Country:US
Mailing Address - Phone:480-946-1430
Mailing Address - Fax:
Practice Address - Street 1:2034 E SOUTHERN AVE
Practice Address - Street 2:SUITE K
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7522
Practice Address - Country:US
Practice Address - Phone:480-946-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3119103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS10534Medicare UPIN