Provider Demographics
NPI:1366950172
Name:PUCKETT, JEFFREY PAUL
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 S RANGER ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-5119
Mailing Address - Country:US
Mailing Address - Phone:760-793-0203
Mailing Address - Fax:
Practice Address - Street 1:1400 N NORMA ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2575
Practice Address - Country:US
Practice Address - Phone:760-499-7406
Practice Address - Fax:760-499-9259
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator