Provider Demographics
NPI:1366950172
Name:PUCKETT, JEFFREY PAUL (ASW)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7596 COMMERCE BLVD APT 19
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-3714
Mailing Address - Country:US
Mailing Address - Phone:760-793-0203
Mailing Address - Fax:
Practice Address - Street 1:2245 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5418
Practice Address - Country:US
Practice Address - Phone:707-565-4993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA122229104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator