Healthcare Provider Details

I. General information

NPI: 1831878271
Provider Name (Legal Business Name): JEFFREY LOUIS SLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3608 STEVE MCQUEEN DR
CHINO HILLS CA
91709-5455
US

IV. Provider business mailing address

1907 BOYS REPUBLIC DR
CHINO HILLS CA
91709-5447
US

V. Phone/Fax

Practice location:
  • Phone: 909-628-1217
  • Fax: 909-306-5427
Mailing address:
  • Phone: 909-628-1217
  • Fax: 909-306-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: