Provider Demographics
NPI:1316471196
Name:JEFFREY LEE EBBAGE
Entity type:Organization
Organization Name:JEFFREY LEE EBBAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:EBBAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-239-1644
Mailing Address - Street 1:275 VICK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-9600
Mailing Address - Country:US
Mailing Address - Phone:831-239-1644
Mailing Address - Fax:
Practice Address - Street 1:6060 GRAHAM HILL RD STE J
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-9764
Practice Address - Country:US
Practice Address - Phone:831-239-1644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty