Provider Demographics
NPI:1285163493
Name:RETKE, JEFFERY W (AA)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:W
Last Name:RETKE
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 NE BARAGER AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-5620
Mailing Address - Country:US
Mailing Address - Phone:1541-464-8775
Mailing Address - Fax:
Practice Address - Street 1:770 SE KANE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3943
Practice Address - Country:US
Practice Address - Phone:541-464-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor