Provider Demographics
NPI:1275140139
Name:ANDERSON, AHJAE
Entity type:Individual
Prefix:
First Name:AHJAE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 EAST PKWY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2501
Mailing Address - Country:US
Mailing Address - Phone:916-709-0139
Mailing Address - Fax:
Practice Address - Street 1:7001 EAST PKWY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2501
Practice Address - Country:US
Practice Address - Phone:916-709-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2025-03-07
Deactivation Date:2025-01-15
Deactivation Code:
Reactivation Date:2025-03-07
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAMPSS-TPEVCF175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)