Provider Demographics
NPI:1285160572
Name:JEFFERSON, MARK ANTHONY JR (MFTI)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:JEFFERSON
Suffix:JR
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W 25TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2208
Mailing Address - Country:US
Mailing Address - Phone:510-409-5391
Mailing Address - Fax:
Practice Address - Street 1:126 W 25TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2208
Practice Address - Country:US
Practice Address - Phone:510-409-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF98404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist