Provider Demographics
NPI:1528428554
Name:LUCERO, JEFFREY HENRY (LCSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:HENRY
Last Name:LUCERO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4687 SE 1ST TERRACE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080
Mailing Address - Country:US
Mailing Address - Phone:801-949-2986
Mailing Address - Fax:
Practice Address - Street 1:4687 SE 1ST TERRACE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080
Practice Address - Country:US
Practice Address - Phone:801-949-2986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4971566-35011041C0700X
IDLCSW-343891041C0700X
ORL80101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID452638687Medicaid
ID452638687Medicare UPIN
ID452638687Medicaid
ID452638687Medicare PIN