Healthcare Provider Details

I. General information

NPI: 1548928898
Provider Name (Legal Business Name): SAMUEL JEFFERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

5284 ADOLFO RD STE 100
CAMARILLO CA
93012-6790
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-3669
  • Fax:
Mailing address:
  • Phone: 805-289-0120
  • Fax: 805-289-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: