Provider Demographics
NPI:1750431490
Name:BRIDGES, JEFFREY KEITH (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KEITH
Last Name:BRIDGES
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 1:576 B ST
Mailing Address - Street 2:SUITE 1-A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5269
Mailing Address - Country:US
Mailing Address - Phone:707-546-5327
Mailing Address - Fax:
Practice Address - Street 1:576 B ST
Practice Address - Street 2:SUITE 1-A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5269
Practice Address - Country:US
Practice Address - Phone:707-546-5327
Practice Address - Fax:707-579-7960
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11129103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA074148OtherMHN PROVIDER #
CA156248OtherVALUEOPTIONS PROV NUM
CAOPL111290OtherBLUE SHIELD PROV #
CA156248OtherVALUEOPTIONS PROV NUM
CAOPL111290OtherBLUE SHIELD PROV #