Provider Demographics
NPI:1518103902
Name:VERSAW, JEFFREY (LISW)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:VERSAW
Suffix:
Gender:M
Credentials:LISW
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 1502
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-1502
Mailing Address - Country:US
Mailing Address - Phone:575-209-1250
Mailing Address - Fax:
Practice Address - Street 1:669 TERRACE AVE.
Practice Address - Street 2:B
Practice Address - City:CHAMA
Practice Address - State:NM
Practice Address - Zip Code:87520
Practice Address - Country:US
Practice Address - Phone:575-209-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-05349104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker