Provider Demographics
NPI:1003533852
Name:JEFFERDS, SUEANN
Entity Type:Individual
Prefix:
First Name:SUEANN
Middle Name:
Last Name:JEFFERDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5146 HALLGATE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-3020
Mailing Address - Country:US
Mailing Address - Phone:419-806-9908
Mailing Address - Fax:
Practice Address - Street 1:5146 HALLGATE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-3020
Practice Address - Country:US
Practice Address - Phone:419-806-9908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0296271Medicaid