=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134197148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY ALLEN RIFFLE PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2006
-----------------------------------------------------
Last Update Date | 04/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | USS DOLPHIN AGSS 555
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-3504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 NORTHCREST DR # 113
-----------------------------------------------------
City | CRESCENT CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95531-2315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-580-9261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 29564
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------