Provider Demographics
NPI:1619212883
Name:TAVERAS, JEFFERSON (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1943
Mailing Address - Country:US
Mailing Address - Phone:888-554-3810
Mailing Address - Fax:206-426-0930
Practice Address - Street 1:255 GORDON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1943
Practice Address - Country:US
Practice Address - Phone:888-554-3810
Practice Address - Fax:206-426-0930
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker