=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689710709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOE M JEFFERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3471 KNICKERBOCKER RD SUITE 508
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76904-8823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-942-7531
-----------------------------------------------------
Fax | 325-942-7532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3471 KNICKERBOCKER RD SUITE 508
-----------------------------------------------------
City | SAN ANGELO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76904-8823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-942-7531
-----------------------------------------------------
Fax | 325-942-7532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOE M JEFFERS
-----------------------------------------------------
Credential | EDD
-----------------------------------------------------
Telephone | 325-942-7531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 12487
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 13927
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 06774
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 24163
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 21733
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------