Provider Demographics
NPI:1114051281
Name:JEFFRIES, MARY VIRGINIA (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:VIRGINIA
Last Name:JEFFRIES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 N MAR VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1127
Mailing Address - Country:US
Mailing Address - Phone:626-793-9226
Mailing Address - Fax:
Practice Address - Street 1:11565 LAUREL CANYON BLVD
Practice Address - Street 2:#100
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4168
Practice Address - Country:US
Practice Address - Phone:818-365-4723
Practice Address - Fax:818-365-3475
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW12041225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner