Provider Demographics
NPI:1093450389
Name:JEFFRIES, DYMOND T
Entity Type:Individual
Prefix:
First Name:DYMOND
Middle Name:T
Last Name:JEFFRIES
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 1:124 BRIGHTON DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44301-1751
Mailing Address - Country:US
Mailing Address - Phone:330-329-8050
Mailing Address - Fax:
Practice Address - Street 1:124 BRIGHTON DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44301-1751
Practice Address - Country:US
Practice Address - Phone:330-329-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0474952Medicaid