Provider Demographics
NPI:1649324500
Name:GOLD, JERRY (PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GOLD
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 1:8139 CAMINITO SONOMA
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2923
Mailing Address - Country:US
Mailing Address - Phone:619-260-7111
Mailing Address - Fax:
Practice Address - Street 1:8139 CAMINITO SONOMA
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-2923
Practice Address - Country:US
Practice Address - Phone:619-260-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9262103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL92620OtherBLUE SHIELD
CAPR0092620OtherMEDI-CAL
CA06E6701OtherCHAMPUS
CA00PL92620OtherBLUE SHIELD