1205900032 NPI number — MR. JEFFERSON TUCKER EDMONDS MFT

Table of content: MR. JEFFERSON TUCKER EDMONDS MFT (NPI 1205900032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205900032 NPI number — MR. JEFFERSON TUCKER EDMONDS MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMONDS
Provider First Name:
JEFFERSON
Provider Middle Name:
TUCKER
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205900032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 609001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92160-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-528-4600
Provider Business Mailing Address Fax Number:
619-528-4625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9620 CHESAPEAKE DR
Provider Second Line Business Practice Location Address:
STE. 206
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-814-6590
Provider Business Practice Location Address Fax Number:
619-814-6591
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  LMFT36498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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