Provider Demographics
NPI:1023551900
Name:FRED JEFFERSON
Entity Type:Organization
Organization Name:FRED JEFFERSON
Other - Org Name:FRED JEFFERSON 142
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-929-0738
Mailing Address - Street 1:1448 E 142ND ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90222-3702
Mailing Address - Country:US
Mailing Address - Phone:310-929-0738
Mailing Address - Fax:310-763-0357
Practice Address - Street 1:1448 E 142ND ST
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-3702
Practice Address - Country:US
Practice Address - Phone:310-763-1660
Practice Address - Fax:310-763-0357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children