Active NPI
Jennifer Rose Vanderburg, PSY.D
- Clinical Psychologist
- Huntington Beach, CA
National Provider Identifier
1871695866
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY 17308
- Practice address
- 5762 Bolsa Ave
Suite 107
Huntington Beach, CA 92649-1172 - Phone
- (562) 804-5522
- NPI assigned
- Sep 1, 2006
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY 17308 | CA | Primary |
Addresses
Primary practice location
5762 Bolsa Ave
Suite 107
Huntington Beach, CA 92649-1172
Mailing address
PO Box 15603
Long Beach, CA 90815-0603
Phone (562) 804-5522
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Aug 9, 2023 through Aug 9, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY 17308 | CA | MD | Clinical Psychologist |
| 17308 | CA | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1157068800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1871695866",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 15603",
"city": "LONG BEACH",
"state": "CA",
"postal_code": "908150603",
"telephone_number": "562-804-5522"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5762 BOLSA AVE",
"address_2": "SUITE 107",
"city": "HUNTINGTON BEACH",
"state": "CA",
"postal_code": "926491172",
"telephone_number": "562-804-5522"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VANDERBURG",
"first_name": "JENNIFER",
"middle_name": "ROSE",
"name_prefix": "Dr.",
"credential": "PSY.D",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2006-09-01",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY 17308",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Huntington Beach, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.