Provider Demographics
NPI:1982071122
Name:WHITE, JEFFREY SAMUEL (LMFT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SAMUEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 30TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3497
Mailing Address - Country:US
Mailing Address - Phone:619-428-1000
Mailing Address - Fax:
Practice Address - Street 1:9330 BASELINE RD STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701-5827
Practice Address - Country:US
Practice Address - Phone:909-908-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104008106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist