Provider Demographics
NPI:1770899296
Name:JEFFRIES, ALVA REENE (MA)
Entity type:Individual
Prefix:MS
First Name:ALVA
Middle Name:REENE
Last Name:JEFFRIES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:ALVA
Other - Middle Name:REENE
Other - Last Name:PRESLEY-JEFFRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:3623 W MORROW DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2323
Mailing Address - Country:US
Mailing Address - Phone:310-487-2639
Mailing Address - Fax:
Practice Address - Street 1:19871 W FREEMONT RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-9512
Practice Address - Country:US
Practice Address - Phone:623-474-6671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-21
Last Update Date:2010-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3785087101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ690976/1043419641OtherAHCCCS
AZ86-60000493Medicaid