Provider Demographics
NPI:1982778932
Name:JEANETTA WARK, JEFFRY DAVID (MA LICSW)
Entity Type:Individual
Prefix:MR
First Name:JEFFRY
Middle Name:DAVID
Last Name:JEANETTA WARK
Suffix:
Gender:M
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 COUNTY ROAD B W STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4037
Mailing Address - Country:US
Mailing Address - Phone:651-698-0768
Mailing Address - Fax:
Practice Address - Street 1:1751 COUNTY ROAD B W STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4037
Practice Address - Country:US
Practice Address - Phone:651-698-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN094591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
13GS2WAOtherBCBS
483889OtherVALUE OPTIONS