Provider Demographics
NPI:1538490115
Name:EBBAGE, JEFFREY LEE
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEE
Last Name:EBBAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3614
Mailing Address - Country:US
Mailing Address - Phone:831-429-8350
Mailing Address - Fax:
Practice Address - Street 1:709 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3614
Practice Address - Country:US
Practice Address - Phone:831-429-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherMEDICAL