Provider Demographics
NPI:1336601731
Name:STEPHENS, JEFFREY PATRICK
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PATRICK
Last Name:STEPHENS
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 1:21 LAKESIDE CT
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1906
Mailing Address - Country:US
Mailing Address - Phone:313-580-3861
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6070
Practice Address - Country:US
Practice Address - Phone:970-810-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0009417390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program