Provider Demographics
NPI:1053015180
Name:CLIFFORD, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CLIFFORD
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 1:4625 MOUNTAIN LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-1450
Mailing Address - Country:US
Mailing Address - Phone:530-246-7172
Mailing Address - Fax:
Practice Address - Street 1:4625 MOUNTAIN LAKES BLVD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-1450
Practice Address - Country:US
Practice Address - Phone:530-246-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst