Provider Demographics
NPI:1821243601
Name:MADDEN, JEFFREY FORREST (MFT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:FORREST
Last Name:MADDEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32605 US HIGHWAY 79 STE 206
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-6839
Mailing Address - Country:US
Mailing Address - Phone:951-216-0640
Mailing Address - Fax:
Practice Address - Street 1:32605 US HIGHWAY 79 STE 206
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-6839
Practice Address - Country:US
Practice Address - Phone:951-216-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist