Provider Demographics
NPI:1386339042
Name:SEIFRIDSBERGER, JESSE ERIN (RADT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:ERIN
Last Name:SEIFRIDSBERGER
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 N SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-2618
Mailing Address - Country:US
Mailing Address - Phone:626-421-1074
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1686
Practice Address - Country:US
Practice Address - Phone:818-285-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1386170420101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)