Healthcare Provider Details

I. General information

NPI: 1528428554
Provider Name (Legal Business Name): JEFFREY HENRY LUCERO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4687 SE 1ST TERRACE
GRESHAM OR
97080
US

IV. Provider business mailing address

4687 SE 1ST TERRACE
GRESHAM OR
97080
US

V. Phone/Fax

Practice location:
  • Phone: 801-949-2986
  • Fax:
Mailing address:
  • Phone: 801-949-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4971566-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-34389
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL8010
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier452638687
Identifier TypeMEDICAID
Identifier StateID
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: