Provider Demographics
NPI:1407135775
Name:JEFFERIES, JERALD J (LCSW)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:J
Last Name:JEFFERIES
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:PO BOX 3986
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3986
Mailing Address - Country:US
Mailing Address - Phone:801-928-8567
Mailing Address - Fax:801-419-0699
Practice Address - Street 1:1140 36TH ST STE 285
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2064
Practice Address - Country:US
Practice Address - Phone:801-928-8567
Practice Address - Fax:801-419-0699
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119437-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical