Provider Demographics
NPI:1538411798
Name:HEGDE, JAYANTA (PHD)
Entity type:Individual
Prefix:DR
First Name:JAYANTA
Middle Name:
Last Name:HEGDE
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 1:1701 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6041
Mailing Address - Country:US
Mailing Address - Phone:520-241-3033
Mailing Address - Fax:
Practice Address - Street 1:1530 MONTEREY ST
Practice Address - Street 2:STE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2969
Practice Address - Country:US
Practice Address - Phone:520-241-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26420103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty