Basic Information
| Provider Information | |||||||||
| NPI: | 1013269018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIST | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1640 | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960931640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306231362 | ||||||||
| FaxNumber: | 5306235830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306231362 | ||||||||
| FaxNumber: | 5306235830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.