Provider Demographics
NPI:1962563361
Name:MARY JO JEFFRES PHD, LLC
Entity type:Organization
Organization Name:MARY JO JEFFRES PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFRES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-463-0890
Mailing Address - Street 1:103 N 5TH ST E
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-4402
Mailing Address - Country:US
Mailing Address - Phone:307-463-0890
Mailing Address - Fax:307-463-0891
Practice Address - Street 1:103 N 5TH ST E
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4402
Practice Address - Country:US
Practice Address - Phone:307-463-0890
Practice Address - Fax:307-463-0891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121869700Medicaid
WYW20556Medicare PIN
WYW20556Medicare PIN
MT000050249Medicare PIN