1497263321 NPI number — JEFFERY THOMAS ACKERLY ADDICTIONS COUNSELOR

Table of content: JEFFERY THOMAS ACKERLY ADDICTIONS COUNSELOR (NPI 1497263321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497263321 NPI number — JEFFERY THOMAS ACKERLY ADDICTIONS COUNSELOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACKERLY
Provider First Name:
JEFFERY
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ADDICTIONS COUNSELOR
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497263321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95502-6310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-444-6262
Provider Business Mailing Address Fax Number:
707-442-1191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95501-2028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-443-4237
Provider Business Practice Location Address Fax Number:
707-460-3380
Provider Enumeration Date:
01/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com