Basic Information
| Provider Information | |||||||||
| NPI: | 1104086040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAY | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | CORVUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1385 MISSION ST | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158644002 | ||||||||
| FaxNumber: | 4158647093 | ||||||||
| Practice Location | |||||||||
| Address1: | 1385 MISSION ST | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941032623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158644002 | ||||||||
| FaxNumber: | 4158647093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2008 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.