Provider Demographics
NPI:1023764594
Name:DAVIS, IKE LENARD JR
Entity type:Individual
Prefix:
First Name:IKE
Middle Name:LENARD
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 GLEN COVE MARINA RD E STE 102
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7290
Mailing Address - Country:US
Mailing Address - Phone:707-648-2000
Mailing Address - Fax:
Practice Address - Street 1:160 GLEN COVE MARINA RD E STE 102
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7290
Practice Address - Country:US
Practice Address - Phone:707-648-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171M00000X
CA18224101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator