Provider Demographics
NPI:1932847100
Name:JEFFORDS, TRAVIS JERMAIN (LCMHCA, MS, MDIV)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JERMAIN
Last Name:JEFFORDS
Suffix:
Gender:M
Credentials:LCMHCA, MS, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E 5TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2472
Mailing Address - Country:US
Mailing Address - Phone:704-375-5354
Mailing Address - Fax:
Practice Address - Street 1:167 SHADY GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9664
Practice Address - Country:US
Practice Address - Phone:980-443-5814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health