Provider Demographics
NPI:1861766339
Name:KRUGER, JEFFREY MICHAEL
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KRUGER
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:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-3868
Mailing Address - Country:US
Mailing Address - Phone:951-663-4827
Mailing Address - Fax:
Practice Address - Street 1:102 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4121
Practice Address - Country:US
Practice Address - Phone:951-663-4827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689715591Medicaid