Provider Demographics
NPI:1346840832
Name:ANDERSON, JEFFERY WAYNE
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:WAYNE
Last Name:ANDERSON
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 1:229 WOODLAND SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GRAMBLING
Mailing Address - State:LA
Mailing Address - Zip Code:71245-2452
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1760 TEXAS ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-3429
Practice Address - Country:US
Practice Address - Phone:318-238-8801
Practice Address - Fax:318-238-8801
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator