Provider Demographics
NPI:1265535660
Name:MAR, JEFFREY B (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:MAR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2554 WOODBURY DR
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-9364
Mailing Address - Country:US
Mailing Address - Phone:559-281-1029
Mailing Address - Fax:
Practice Address - Street 1:2554 WOODBURY DR
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-9364
Practice Address - Country:US
Practice Address - Phone:559-281-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PL114970103T00000X
CAPSY114970103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL114970Medicare UPIN