Basic Information
| Provider Information | |||||||||
| NPI: | 1831536028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | LAADC-, APCC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2116 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900181353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233349000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2116 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900181353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233349000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T0912071404 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | APCC6717 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | CATC NO. 156320 III | 01 | CA | ADDICTION CERTIFICATION BOARD OF CALIFORNIA | OTHER | T0912071404 | 01 | CA | REGISTERED ADDICTION SPECIALIST | OTHER |