Provider Demographics
NPI:1154445088
Name:BACKE, JEFFREY E
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
Last Name:BACKE
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 1:1721 S INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7535
Mailing Address - Country:US
Mailing Address - Phone:660-826-3367
Mailing Address - Fax:660-826-8847
Practice Address - Street 1:1721 S INGRAM AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7535
Practice Address - Country:US
Practice Address - Phone:660-826-3367
Practice Address - Fax:660-826-8847
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional