Provider Demographics
NPI:1528374774
Name:JEFFERY, JEFF ROBERT (CATC)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:ROBERT
Last Name:JEFFERY
Suffix:
Gender:M
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-1245
Mailing Address - Country:US
Mailing Address - Phone:619-302-1846
Mailing Address - Fax:805-862-4901
Practice Address - Street 1:117 S. BENWILEY AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458
Practice Address - Country:US
Practice Address - Phone:805-332-3439
Practice Address - Fax:805-862-4901
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101687101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1528374774Medicaid