Provider Demographics
NPI:1215102991
Name:CONKLIN, JEFF DONOVAN
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:DONOVAN
Last Name:CONKLIN
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 1:11099 SUCCESS CROSS RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-3470
Mailing Address - Country:US
Mailing Address - Phone:530-575-9056
Mailing Address - Fax:
Practice Address - Street 1:565 BRUNSWICK RD
Practice Address - Street 2:STE 10
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9529
Practice Address - Country:US
Practice Address - Phone:530-575-9056
Practice Address - Fax:530-271-5992
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24549103TC1900X
CAPSY 24549101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling