Provider Demographics
NPI:1316688328
Name:BEAVER, JEFFREY WAYNE JR (LCSWA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
Last Name:BEAVER
Suffix:JR
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-202-3155
Mailing Address - Fax:910-202-5772
Practice Address - Street 1:615 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6431
Practice Address - Country:US
Practice Address - Phone:910-202-3155
Practice Address - Fax:910-202-5772
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0173091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922022607Medicaid