Provider Demographics
NPI:1447424031
Name:WIRTH, JEFFREY RANDALL (MFT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RANDALL
Last Name:WIRTH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6194 OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2167
Mailing Address - Country:US
Mailing Address - Phone:909-804-2355
Mailing Address - Fax:
Practice Address - Street 1:8485 TAMARIND AVE , CA
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3975
Practice Address - Country:US
Practice Address - Phone:909-277-3189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30166101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health