Provider Demographics
NPI:1730274010
Name:COLE, JEFF R (PHD)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:R
Last Name:COLE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 NE STEPHENS ST STE A
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3166
Mailing Address - Country:US
Mailing Address - Phone:541-643-1375
Mailing Address - Fax:541-464-8700
Practice Address - Street 1:693 NE STEPHENS STREET
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3166
Practice Address - Country:US
Practice Address - Phone:541-643-1375
Practice Address - Fax:541-464-8700
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR297201Medicaid
107001Medicare ID - Type Unspecified
OR297201Medicaid