Basic Information
| Provider Information | |||||||||
| NPI: | 1114554227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZAVALA | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1153 ASH ST STE B | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054583659 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2945 MCMILLAN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054394890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2020 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 41575 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.