Provider Demographics
NPI:1003866021
Name:CODELLA, JEFFREY R (MSED)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:R
Last Name:CODELLA
Suffix:
Gender:M
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-5293
Mailing Address - Country:US
Mailing Address - Phone:508-828-9675
Mailing Address - Fax:508-821-2519
Practice Address - Street 1:1 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-5293
Practice Address - Country:US
Practice Address - Phone:508-828-9675
Practice Address - Fax:508-821-2519
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5529101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health