Provider Demographics
NPI:1871695866
Name:VANDERBURG, JENNIFER ROSE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSE
Last Name:VANDERBURG
Suffix:
Gender:F
Credentials:PSYD
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 15603
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-0603
Mailing Address - Country:US
Mailing Address - Phone:562-804-5522
Mailing Address - Fax:
Practice Address - Street 1:5762 BOLSA AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:562-804-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 17308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical