Provider Demographics
NPI:1659004802
Name:LU, JEFFERSON
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:LU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BRIDGES CIR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:VT
Mailing Address - Zip Code:05674-9403
Mailing Address - Country:US
Mailing Address - Phone:802-771-7403
Mailing Address - Fax:
Practice Address - Street 1:202 BRIDGES CIR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:VT
Practice Address - Zip Code:05674-9403
Practice Address - Country:US
Practice Address - Phone:802-771-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst