Provider Demographics
NPI:1467159111
Name:PHAM, JEFFREY (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 E PALM CANYON DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-1623
Mailing Address - Country:US
Mailing Address - Phone:760-627-9177
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 301
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3838
Practice Address - Country:US
Practice Address - Phone:760-627-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022483363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health