Provider Demographics
NPI:1174990063
Name:JAYANTY, AMELIA GABRIELLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:GABRIELLE
Last Name:JAYANTY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 SUMMIT ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3416
Mailing Address - Country:US
Mailing Address - Phone:713-859-7703
Mailing Address - Fax:
Practice Address - Street 1:2940 SUMMIT ST STE 2D
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3416
Practice Address - Country:US
Practice Address - Phone:713-859-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 390200000X
CA33674103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program