MEDICARE: MARY JO JEFFRES PHD, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	421	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962563361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARY JO JEFFRES PHD, LLC

Provider Business Mailing Address
First Line	:	103 N 5TH ST E
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-4402
Country	:	US
Telephone Number	:	307-463-0890
Fax Number	:	307-463-0891

Provider Business Practice Location Address
First Line	:	103 N 5TH ST E
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-4402
Country	:	US
Telephone Number	:	307-463-0890
Fax Number	:	307-463-0891

Authorized Official
Title or Position	:	OWNER
Name	:	MARY JO JEFFRES
Credential	:	PHD
Telephone Number	:	307-463-0890

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	07/21/2022

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