Provider Demographics
NPI:1609919562
Name:SKILLINGSTEAD, JEFF DAVID (MAC)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:DAVID
Last Name:SKILLINGSTEAD
Suffix:
Gender:M
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 CEDARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-9507
Mailing Address - Country:US
Mailing Address - Phone:360-431-6908
Mailing Address - Fax:
Practice Address - Street 1:1329 BROADWAY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3747
Practice Address - Country:US
Practice Address - Phone:360-431-6908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60225625101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health