Provider Demographics
NPI:1033414586
Name:MANCARUSO, JEFFREY LEE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:MANCARUSO
Suffix:
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 1:508-510 S SECOND AVE,
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-974-8122
Mailing Address - Fax:626-974-8198
Practice Address - Street 1:508-510 S SECOND AVE,
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-974-8122
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA686969106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist