Provider Demographics
NPI:1407905284
Name:JEFFUS, EDISON DALE JR (PHD)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:DALE
Last Name:JEFFUS
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-2934
Mailing Address - Country:US
Mailing Address - Phone:918-241-1149
Mailing Address - Fax:918-749-5506
Practice Address - Street 1:3220 S PEORIA AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-2003
Practice Address - Country:US
Practice Address - Phone:918-749-5506
Practice Address - Fax:918-749-5506
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK636103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical