Provider Demographics
NPI:1174560189
Name:WILLIS, JOHN JEFFREY (LCSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JEFFREY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 N PARHAM RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-3156
Mailing Address - Country:US
Mailing Address - Phone:804-270-1124
Mailing Address - Fax:804-270-2090
Practice Address - Street 1:2305 N PARHAM RD
Practice Address - Street 2:SUITE 3
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-3156
Practice Address - Country:US
Practice Address - Phone:804-270-1124
Practice Address - Fax:804-270-2090
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040024841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical