Provider Demographics
NPI:1568531580
Name:BROMBERG, JEFFREY (PHD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 PERALTA BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3827
Mailing Address - Country:US
Mailing Address - Phone:510-791-8120
Mailing Address - Fax:
Practice Address - Street 1:2450 PERALTA BLVD
Practice Address - Street 2:SUITE 212
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3827
Practice Address - Country:US
Practice Address - Phone:510-791-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11132103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist