Provider Demographics
NPI:1861747552
Name:OUTLAW, JASEON S (PHD)
Entity type:Individual
Prefix:DR
First Name:JASEON
Middle Name:S
Last Name:OUTLAW
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 1:13847 E 14TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2626
Mailing Address - Country:US
Mailing Address - Phone:510-463-1302
Mailing Address - Fax:
Practice Address - Street 1:13847 E 14TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2626
Practice Address - Country:US
Practice Address - Phone:510-463-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical