Provider Demographics
NPI:1083103956
Name:TIMACDOG, JEFFENSEN JAY
Entity type:Individual
Prefix:
First Name:JEFFENSEN JAY
Middle Name:
Last Name:TIMACDOG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9920 PACIFIC HEIGHTS BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4361
Mailing Address - Country:US
Mailing Address - Phone:619-345-0086
Mailing Address - Fax:
Practice Address - Street 1:6920 MIRAMAR RD STE 326
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2642
Practice Address - Country:US
Practice Address - Phone:619-345-0086
Practice Address - Fax:619-345-0086
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008823363L00000X, 363LP0808X
CANP95008823363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care