Provider Demographics
NPI:1982105987
Name:DICTADO, JERMAINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JERMAINE
Middle Name:
Last Name:DICTADO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 BALBOA AVE STE 803
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6920
Mailing Address - Country:US
Mailing Address - Phone:619-258-1381
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE STE 803
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6920
Practice Address - Country:US
Practice Address - Phone:619-258-1381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-24
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32039103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral