Basic Information
| Provider Information | |||||||||
| NPI: | 1992384044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFRIES | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | JOHANNA | ||||||||
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| Credential: | M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 CANDLELIGHT BLVD APT 44 | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346013129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525378339 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3404 N LECANTO HWY STE D | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344653569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524194856 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2021 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMH18168 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.