Provider Demographics
NPI:1629013784
Name:JEFFRES, MARY JO (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:JEFFRES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N 5TH ST E
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4402
Mailing Address - Country:US
Mailing Address - Phone:307-463-0890
Mailing Address - Fax:307-463-0891
Practice Address - Street 1:103 N 5TH ST E
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4402
Practice Address - Country:US
Practice Address - Phone:307-463-0890
Practice Address - Fax:307-463-0891
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2015-12-23
Deactivation Date:2007-12-07
Deactivation Code:
Reactivation Date:2008-10-29
Provider Licenses
StateLicense IDTaxonomies
WY421103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY147314Medicaid
WY147314Medicaid
MT050249Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER