Provider Demographics
NPI:1386966406
Name:JEFFERIES, DOMINICK ANTONIO (MSW, CSW)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:ANTONIO
Last Name:JEFFERIES
Suffix:
Gender:M
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6035
Mailing Address - Country:US
Mailing Address - Phone:801-859-8999
Mailing Address - Fax:
Practice Address - Street 1:4609 S 2300 E
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4527
Practice Address - Country:US
Practice Address - Phone:801-461-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical