Provider Demographics
NPI:1700496080
Name:WARREN, JEFFRY CLARY (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:CLARY
Last Name:WARREN
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 1:1224 PROSPECT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-3609
Mailing Address - Country:US
Mailing Address - Phone:858-454-0576
Mailing Address - Fax:
Practice Address - Street 1:1224 PROSPECT ST STE 100
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-3609
Practice Address - Country:US
Practice Address - Phone:858-454-0576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5689103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist