Provider Demographics
NPI:1376938068
Name:JERGENS, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:JERGENS
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 1:12040 98TH AVE NE STE 204
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4217
Mailing Address - Country:US
Mailing Address - Phone:425-658-3016
Mailing Address - Fax:
Practice Address - Street 1:12040 98TH AVE NE STE 204
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4217
Practice Address - Country:US
Practice Address - Phone:425-658-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60447627103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst