MEDICARE: STEPHEN JEFFERSON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	SUDRC21405	CA

General Provider Information

NPI Number	:	1831927029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN JEFFERSON

Provider Business Mailing Address
First Line	:	PO BOX 33568
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92163-3568
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:	619-374-7134

Provider Business Practice Location Address
First Line	:	14340 ELSWORTH ST STE 108109
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92553-9019
Country	:	US
Telephone Number	:	951-653-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2024
Last Update Date	:	12/29/2025

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