Provider Demographics
NPI:1851064695
Name:STANSBERRY, JEFFREY (LE)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:STANSBERRY
Suffix:
Gender:M
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-6650
Mailing Address - Country:US
Mailing Address - Phone:925-399-1425
Mailing Address - Fax:
Practice Address - Street 1:855 MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-6650
Practice Address - Country:US
Practice Address - Phone:925-399-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9689174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty