Healthcare Provider Details

I. General information

NPI: 1548083785
Provider Name (Legal Business Name): JEREMY SUNDBY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 SUNCAST LN STE 120
EL DORADO HILLS CA
95762-9339
US

IV. Provider business mailing address

4641 POST ST UNIT 5255
EL DORADO HILLS CA
95762-3011
US

V. Phone/Fax

Practice location:
  • Phone: 858-758-0587
  • Fax:
Mailing address:
  • Phone: 858-758-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLCP01559
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY36617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: