Provider Demographics
NPI:1033532536
Name:MANDELKORN, JEFFREY D
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:MANDELKORN
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 1:2686 NW 95TH TER
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4943
Mailing Address - Country:US
Mailing Address - Phone:954-380-8980
Mailing Address - Fax:
Practice Address - Street 1:2419 E COMMERCIAL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4042
Practice Address - Country:US
Practice Address - Phone:954-380-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8957101YM0800X
FLPY 8957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health