Provider Demographics
NPI:1598797771
Name:SNELL, JEFFRY B (PHD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:B
Last Name:SNELL
Suffix:
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:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51102-0328
Mailing Address - Country:US
Mailing Address - Phone:712-279-5836
Mailing Address - Fax:712-279-5883
Practice Address - Street 1:801 5TH ST # 6NW
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1326
Practice Address - Country:US
Practice Address - Phone:712-279-5718
Practice Address - Fax:712-279-5978
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00967103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100251285-00Medicaid
IA0447763Medicaid
IA38170OtherWELLMARK
IAI12400Medicare ID - Type Unspecified
IA38170OtherWELLMARK