Provider Demographics
NPI:1083083851
Name:JEFFERSON, PATRICIA (MSED RN LCADC CCS)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MSED RN LCADC CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WOODBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SEWAREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07077-1351
Mailing Address - Country:US
Mailing Address - Phone:732-636-1931
Mailing Address - Fax:
Practice Address - Street 1:40 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SEWAREN
Practice Address - State:NJ
Practice Address - Zip Code:07077-1351
Practice Address - Country:US
Practice Address - Phone:732-636-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR14629700163W00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse