Provider Demographics
NPI:1023142890
Name:SOLOMON, JERRY (JERRY SOLOMON)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:JERRY SOLOMON
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:SOLOMON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:407 AVALON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2207
Mailing Address - Country:US
Mailing Address - Phone:831-425-8785
Mailing Address - Fax:831-425-2308
Practice Address - Street 1:407 AVALON ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2207
Practice Address - Country:US
Practice Address - Phone:831-425-8785
Practice Address - Fax:831-425-2308
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical