Provider Demographics
NPI:1093413593
Name:JEFFERSON, JAMES HENRY
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HENRY
Last Name:JEFFERSON
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 1:10000 BROOKPARK RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-1102
Mailing Address - Country:US
Mailing Address - Phone:216-741-6786
Mailing Address - Fax:216-741-6653
Practice Address - Street 1:10000 BROOKPARK RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-1102
Practice Address - Country:US
Practice Address - Phone:216-741-6786
Practice Address - Fax:216-741-6653
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC7135156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician