Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003261447 |
---|---|
Provider Name | Mr. Jeffrey White |
First Address | San Luis Obispo, CA 93401-4558 |
Second Address | San Luis Obispo, CA 93401-4558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2016 |
Last Update Date | 22/01/2020 |