Healthcare Provider Details

I. General information

NPI: 1962036962
Provider Name (Legal Business Name): MONDRAY ARNEL JEFFERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 COCO AVE APT 5
LOS ANGELES CA
90008-1415
US

IV. Provider business mailing address

2644 30TH ST STE 100
SANTA MONICA CA
90405-3051
US

V. Phone/Fax

Practice location:
  • Phone: 323-875-6770
  • Fax:
Mailing address:
  • Phone: 310-314-6200
  • Fax: 310-450-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: