Provider Demographics
NPI:1295809382
Name:SANDERS, JEFFREY (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 RED ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8106
Mailing Address - Country:US
Mailing Address - Phone:704-392-1607
Mailing Address - Fax:
Practice Address - Street 1:2505 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-884-2050
Practice Address - Fax:704-852-3501
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003768Medicaid
NC6003768Medicaid