Provider Demographics
NPI:1942913603
Name:FORD, JEFFREY DALE (SUDPT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DALE
Last Name:FORD
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 E NORTH FOOTHILLS DR APT B102
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2716
Mailing Address - Country:US
Mailing Address - Phone:509-953-5768
Mailing Address - Fax:
Practice Address - Street 1:4301 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99224-5157
Practice Address - Country:US
Practice Address - Phone:509-953-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61319735101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)