Provider Demographics
NPI:1982628079
Name:ROGERS, JEFFERSON OWEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:OWEN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4620
Mailing Address - Country:US
Mailing Address - Phone:228-875-6585
Mailing Address - Fax:228-523-4754
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:(116B)
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-5238
Practice Address - Fax:228-523-4754
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS35 589103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical