Provider Demographics
NPI:1043977390
Name:MEADOR, JEFFERY RUSSELL
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:RUSSELL
Last Name:MEADOR
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:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83622-0450
Mailing Address - Country:US
Mailing Address - Phone:208-462-3074
Mailing Address - Fax:
Practice Address - Street 1:25 MIRACLE LN
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:ID
Practice Address - Zip Code:83622
Practice Address - Country:US
Practice Address - Phone:208-462-3074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist