Provider Demographics
NPI:1255438941
Name:TEAL, JEFFREY CLEMAN (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CLEMAN
Last Name:TEAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 HEARTHSIDE LN
Mailing Address - Street 2:
Mailing Address - City:GOLDENDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98620-2317
Mailing Address - Country:US
Mailing Address - Phone:509-773-3258
Mailing Address - Fax:
Practice Address - Street 1:570 HEARTHSIDE LN
Practice Address - Street 2:
Practice Address - City:GOLDENDALE
Practice Address - State:WA
Practice Address - Zip Code:98620-2317
Practice Address - Country:US
Practice Address - Phone:509-773-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001821103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7060833Medicaid
WAAB03590Medicare UPIN