Provider Demographics
NPI:1265995807
Name:EFFERSON, MICHAEL JACOB
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JACOB
Last Name:EFFERSON
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 1:401 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-3327
Mailing Address - Country:US
Mailing Address - Phone:225-361-3017
Mailing Address - Fax:
Practice Address - Street 1:303 VETERAN BLVD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726
Practice Address - Country:US
Practice Address - Phone:225-369-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA011088525Other011088525