Provider Demographics
NPI:1801488085
Name:EVERETT, JEFFREY WILLIAM
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM
Last Name:EVERETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W F ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3201
Mailing Address - Country:US
Mailing Address - Phone:909-986-4550
Mailing Address - Fax:
Practice Address - Street 1:900 E GILBERT ST STE 4
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-3201
Practice Address - Country:US
Practice Address - Phone:714-423-2996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR11400740820OtherCCAPP