Provider Demographics
NPI:1497250161
Name:ANDERSON, NANCY JEAN
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JEAN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 CITRACADO PKWY SPC 40
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-4127
Mailing Address - Country:US
Mailing Address - Phone:760-745-8478
Mailing Address - Fax:760-745-6852
Practice Address - Street 1:737 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4404
Practice Address - Country:US
Practice Address - Phone:760-745-8478
Practice Address - Fax:760-745-6852
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC037290416101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC037290416OtherCADC-CAS