=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831927029
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN JEFFERSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2024
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14340 ELSWORTH ST STE 108109
-----------------------------------------------------
City | MORENO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92553-9019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-653-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33568
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92163-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax | 619-374-7134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | SUDRC21405
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------