Provider Demographics
NPI:1457451908
Name:ANDERSON, JEFFREY ALLAN (LPC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 WATER MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-2981
Mailing Address - Country:US
Mailing Address - Phone:682-472-9200
Mailing Address - Fax:682-472-9200
Practice Address - Street 1:2505 N HWY 360
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-7818
Practice Address - Country:US
Practice Address - Phone:682-206-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160739201Medicaid