Provider Demographics
NPI:1679797104
Name:ANDERSEN, JEFFERY
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:ANDERSEN
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 1:10098 JIBBOOM ST STE 103
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-0229
Mailing Address - Country:US
Mailing Address - Phone:831-278-1056
Mailing Address - Fax:
Practice Address - Street 1:10098 JIBBOOM ST STE 103
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0229
Practice Address - Country:US
Practice Address - Phone:831-278-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 44185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist