Provider Demographics
NPI:1336782085
Name:TIEFENBRUN, JEREMY
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:TIEFENBRUN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:TIEFENBRUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:991 LOMAS SANTA FE DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2141
Mailing Address - Country:US
Mailing Address - Phone:858-209-3241
Mailing Address - Fax:
Practice Address - Street 1:992 1 C LOMAS SANTA FE DR PMB 291
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075
Practice Address - Country:US
Practice Address - Phone:858-209-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician