Provider Demographics
NPI:1881007672
Name:JEFFERSON, JOSEPH ROBERT (PSYD, LMFT, CPRP)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:PSYD, LMFT, CPRP
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 421
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-0421
Mailing Address - Country:US
Mailing Address - Phone:619-980-9549
Mailing Address - Fax:
Practice Address - Street 1:352 MAGNOLIA LN
Practice Address - Street 2:
Practice Address - City:VADNAIS HTS
Practice Address - State:MN
Practice Address - Zip Code:55127-3727
Practice Address - Country:US
Practice Address - Phone:619-980-9549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1031-124106H00000X
MN3198106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty