Provider Demographics
NPI:1245236421
Name:JEFFERS, JOE MAC (EDD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:MAC
Last Name:JEFFERS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 DARLENE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-9005
Mailing Address - Country:US
Mailing Address - Phone:325-942-8191
Mailing Address - Fax:325-942-7532
Practice Address - Street 1:3471 KNICKERBOCKER RD
Practice Address - Street 2:STE 508
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-8826
Practice Address - Country:US
Practice Address - Phone:325-942-7531
Practice Address - Fax:325-942-7532
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21733103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130095OtherMHN/HMC CLAIMS
TX117880OtherSUPERIOR HEALTHPLAN NETWO
TX117880OtherSUPERIOR HEALTHPLAN NETWO