Provider Demographics
NPI:1205900032
Name:EDMONDS, JEFFERSON TUCKER (MFT)
Entity type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:TUCKER
Last Name:EDMONDS
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:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:9620 CHESAPEAKE DR
Practice Address - Street 2:STE. 206
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1369
Practice Address - Country:US
Practice Address - Phone:619-814-6590
Practice Address - Fax:619-814-6591
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT36498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicare PIN