Provider Demographics
NPI:1215044144
Name:YOUNGGREN, JEFFREY NELS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:NELS
Last Name:YOUNGGREN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 DEEP VALLEY DR
Mailing Address - Street 2:# 309
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274
Mailing Address - Country:US
Mailing Address - Phone:310-377-4264
Mailing Address - Fax:310-541-6370
Practice Address - Street 1:827 DEEP VALLEY DR
Practice Address - Street 2:# 309
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274
Practice Address - Country:US
Practice Address - Phone:310-377-4264
Practice Address - Fax:310-541-6370
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4769103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP4769Medicare ID - Type Unspecified