Provider Demographics
NPI:1386411130
Name:DURHAM, JEFFERY
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:DURHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 NEWNAN CROSSING BLVD E APT 6301
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2363
Mailing Address - Country:US
Mailing Address - Phone:314-210-5118
Mailing Address - Fax:
Practice Address - Street 1:2050 NEWNAN CROSSING BLVD E APT 6301
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2363
Practice Address - Country:US
Practice Address - Phone:314-210-5118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician