Provider Demographics
NPI:1508539669
Name:NISS, JEFFREY KENT (CCAPP C7801214)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KENT
Last Name:NISS
Suffix:
Gender:M
Credentials:CCAPP C7801214
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 S SANTA FE AVE APT 28
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-7853
Mailing Address - Country:US
Mailing Address - Phone:760-214-0378
Mailing Address - Fax:
Practice Address - Street 1:733 S SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5939
Practice Address - Country:US
Practice Address - Phone:760-945-5290
Practice Address - Fax:760-945-7765
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC7801214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty