Provider Demographics
NPI:1649697178
Name:HALL, JEFFERY
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:HALL
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 1:133 N F ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6033
Mailing Address - Country:US
Mailing Address - Phone:805-735-7525
Mailing Address - Fax:805-737-0524
Practice Address - Street 1:133 N F ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6033
Practice Address - Country:US
Practice Address - Phone:805-735-7525
Practice Address - Fax:805-737-0524
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH1106211834171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1548383110OtherOUT PATIENT DRUGFREE