Provider Demographics
NPI:1912965476
Name:SUSSMAN, JED M (PHD)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:M
Last Name:SUSSMAN
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 942
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566
Mailing Address - Country:US
Mailing Address - Phone:925-600-8199
Mailing Address - Fax:
Practice Address - Street 1:4466 BLACK AVE
Practice Address - Street 2:STE H
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566
Practice Address - Country:US
Practice Address - Phone:925-600-8199
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7553103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL75530Medicare ID - Type Unspecified