Provider Demographics
NPI:1093187031
Name:JEFFERSON, JO ETTA
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:ETTA
Last Name:JEFFERSON
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 1:3013 N RANCHO DR
Mailing Address - Street 2:SUITE 127
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3345
Mailing Address - Country:US
Mailing Address - Phone:702-639-4400
Mailing Address - Fax:
Practice Address - Street 1:3013 N RANCHO DR
Practice Address - Street 2:SUITE 127
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3345
Practice Address - Country:US
Practice Address - Phone:702-639-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner