MEDICARE: PROGRESSIVE RECOVERY COUNSELING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	48059	CA

General Provider Information

NPI Number	:	1346602240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE RECOVERY COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	312 S CEDROS AVE
Second Line	:	SUITE 334
City	:	SOLANA BEACH
State	:	CA
Zip	:	92075-1979
Country	:	US
Telephone Number	:	619-518-3415
Fax Number	:	760-304-4080

Provider Business Practice Location Address
First Line	:	312 S CEDROS AVE
Second Line	:	SUITE 334
City	:	SOLANA BEACH
State	:	CA
Zip	:	92075-1979
Country	:	US
Telephone Number	:	619-518-3415
Fax Number	:	760-304-4080

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	MICHELE JENSEN
Credential	:	MFT
Telephone Number	:	619-518-3415

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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