Healthcare Provider Details

I. General information

NPI: 1215102991
Provider Name (Legal Business Name): JEFF DONOVAN CONKLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 BRUNSWICK RD STE 10
GRASS VALLEY CA
95945-9529
US

IV. Provider business mailing address

11099 SUCCESS CROSS RD
NEVADA CITY CA
95959-3470
US

V. Phone/Fax

Practice location:
  • Phone: 530-575-9056
  • Fax: 530-271-5992
Mailing address:
  • Phone: 530-575-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSY 24549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY24549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: