Healthcare Provider Details

I. General information

NPI: 1093344194
Provider Name (Legal Business Name): JEFFREY JOSEPH NILES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PINE ST STE 1250
SAN FRANCISCO CA
94111-5235
US

IV. Provider business mailing address

680 AMERICAN AVE STE 302
KING OF PRUSSIA PA
19406-4023
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS024072
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A22974
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number330842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: