Provider Demographics
NPI:1740361013
Name:CHILDERS, JEFFREY BRENNON (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BRENNON
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 COWPER DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2229
Mailing Address - Country:US
Mailing Address - Phone:919-368-3522
Mailing Address - Fax:
Practice Address - Street 1:3000 FALSTAFF RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1813
Practice Address - Country:US
Practice Address - Phone:919-250-3133
Practice Address - Fax:919-250-1176
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005006922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902475Medicaid
NC5902475Medicaid