Provider Demographics
NPI:1578344503
Name:VAN AUSDALL, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:VAN AUSDALL
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 1:1969 BUTTERCUP LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-4055
Mailing Address - Country:US
Mailing Address - Phone:530-710-4047
Mailing Address - Fax:
Practice Address - Street 1:1969 BUTTERCUP LN
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-4055
Practice Address - Country:US
Practice Address - Phone:530-710-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician