Provider Demographics
NPI:1619018231
Name:ROGERS, JEFFERSON CARL (MFC)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:CARL
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3033
Mailing Address - Country:US
Mailing Address - Phone:760-256-5026
Mailing Address - Fax:760-256-5092
Practice Address - Street 1:805 E MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3033
Practice Address - Country:US
Practice Address - Phone:760-256-5026
Practice Address - Fax:760-256-5092
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist