Provider Demographics
NPI:1255215984
Name:JEFFERSON, JEANIE LYN (LCSW)
Entity type:Individual
Prefix:
First Name:JEANIE
Middle Name:LYN
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEANIE
Other - Middle Name:
Other - Last Name:JENICKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:14 S WILLSON AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6232
Mailing Address - Country:US
Mailing Address - Phone:804-215-6803
Mailing Address - Fax:
Practice Address - Street 1:1708 ARBOR MILL CIR APT 1112
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-1808
Practice Address - Country:US
Practice Address - Phone:817-690-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical