Provider Demographics
NPI:1235262809
Name:HILDRETH, JEFFREY LEROY (LPA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LEROY
Last Name:HILDRETH
Suffix:
Gender:M
Credentials:LPA
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 14169
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27620-4169
Mailing Address - Country:US
Mailing Address - Phone:919-857-9108
Mailing Address - Fax:919-250-3943
Practice Address - Street 1:401 E WHITAKER MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2631
Practice Address - Country:US
Practice Address - Phone:919-857-9108
Practice Address - Fax:919-250-3943
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0511103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107310Medicaid