Provider Demographics
NPI:1154713451
Name:ALLEN, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:ALLEN
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:PO BOX 601552
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-1552
Mailing Address - Country:US
Mailing Address - Phone:619-630-5806
Mailing Address - Fax:
Practice Address - Street 1:2831 CAMINO DEL RIO S STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3828
Practice Address - Country:US
Practice Address - Phone:619-630-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2019-09-05
Deactivation Date:2019-08-21
Deactivation Code:
Reactivation Date:2019-09-05
Provider Licenses
StateLicense IDTaxonomies
CA114523106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist