=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215543160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMY MAST, LICENSED MARRIAGE AND FAMILY THERAPIST, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2020
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3585 MAPLE ST STE 233
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-9148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-256-3497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3585 MAPLE ST STE 233
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-9148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-256-3497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEREMY MAST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-256-3497
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------