Provider Demographics
NPI:1447949227
Name:JEFFRIES, KEVIN WESLEY (LCDC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WESLEY
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-4342
Mailing Address - Country:US
Mailing Address - Phone:817-291-3235
Mailing Address - Fax:
Practice Address - Street 1:715 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-3012
Practice Address - Country:US
Practice Address - Phone:903-872-4442
Practice Address - Fax:903-872-2125
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16142101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)