Provider Demographics
NPI:1720428709
Name:WELLER, JESSE BRYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:BRYAN
Last Name:WELLER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CAMINAR / 2600 S. EL CAMINO REAL
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403
Mailing Address - Country:US
Mailing Address - Phone:650-578-8691
Mailing Address - Fax:
Practice Address - Street 1:75 RANCHO CAMINO DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4728
Practice Address - Country:US
Practice Address - Phone:323-435-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33254103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical