Provider Demographics
NPI:1831529395
Name:JEFFERIES, MAXIMILLIAN A (LPC, NCC, MFT)
Entity type:Individual
Prefix:
First Name:MAXIMILLIAN
Middle Name:A
Last Name:JEFFERIES
Suffix:
Gender:M
Credentials:LPC, NCC, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 BOXELDER RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-1673
Mailing Address - Country:US
Mailing Address - Phone:470-423-2671
Mailing Address - Fax:
Practice Address - Street 1:474 BOXELDER RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-1673
Practice Address - Country:US
Practice Address - Phone:470-423-2671
Practice Address - Fax:678-870-2274
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007538101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA461399935Medicaid