Provider Demographics
NPI:1720285422
Name:DISTELBERG, JEFFREY D (MFT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:DISTELBERG
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 1:325 W HOSPITALITY LN
Mailing Address - Street 2:STE. #312
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3243
Mailing Address - Country:US
Mailing Address - Phone:909-386-5500
Mailing Address - Fax:909-386-5520
Practice Address - Street 1:325 W HOSPITALITY LN
Practice Address - Street 2:STE. #312
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3243
Practice Address - Country:US
Practice Address - Phone:909-386-5500
Practice Address - Fax:909-386-5520
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37522106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist