Provider Demographics
NPI:1689451569
Name:VAN BEURDEN, JENNIFER MYRA MARIE (R1464360322)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MYRA MARIE
Last Name:VAN BEURDEN
Suffix:
Gender:F
Credentials:R1464360322
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1552
Mailing Address - Country:US
Mailing Address - Phone:805-235-5615
Mailing Address - Fax:
Practice Address - Street 1:2460 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1552
Practice Address - Country:US
Practice Address - Phone:805-235-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1464360322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)