Basic Information
| Provider Information | |||||||||
| NPI: | 1982137568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOFOED | ||||||||
| FirstName: | JAMIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2016 MCLAREN DR APT 140 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163964268 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9355 E STOCKTON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166831109 | ||||||||
| FaxNumber: | 9166831140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2017 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-25752 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.