Provider Demographics
NPI:1073240305
Name:JEFFERSON, RICHARD D (SUDP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:D
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-4143
Mailing Address - Country:US
Mailing Address - Phone:360-510-4842
Mailing Address - Fax:
Practice Address - Street 1:8212 S MARCH POINT RD
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-8684
Practice Address - Country:US
Practice Address - Phone:360-588-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)