Provider Demographics
NPI:1497207252
Name:JEFFREYS, JOHNNA LAYNE (SUDP CP- 61191773)
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:LAYNE
Last Name:JEFFREYS
Suffix:
Gender:F
Credentials:SUDP CP- 61191773
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21810 NE 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-7747
Mailing Address - Country:US
Mailing Address - Phone:844-777-9242
Mailing Address - Fax:360-397-7477
Practice Address - Street 1:21810 NE 37TH AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-7747
Practice Address - Country:US
Practice Address - Phone:844-777-9242
Practice Address - Fax:360-397-7477
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60660639101YA0400X
WA61191773101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)