MEDICARE: JEFFREY SAMUEL WHITE LMFT

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	104008	CA

General Provider Information

NPI Number	:	1982071122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY SAMUEL WHITE LMFT

Provider Business Mailing Address
First Line	:	1465 30TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-3497
Country	:	US
Telephone Number	:	619-428-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	9330 BASELINE RD STE 102
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91701-5827
Country	:	US
Telephone Number	:	909-908-3390
Fax Number	:

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

Provider Enumeration Date	:	08/24/2015
Last Update Date	:	01/19/2018

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