Provider Demographics
NPI:1104209469
Name:JEFFCOAT, TAWANDA JEANNETTE
Entity Type:Individual
Prefix:
First Name:TAWANDA
Middle Name:JEANNETTE
Last Name:JEFFCOAT
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 1:225 FILBERT AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2549
Mailing Address - Country:US
Mailing Address - Phone:302-543-3219
Mailing Address - Fax:
Practice Address - Street 1:225 FILBERT AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2549
Practice Address - Country:US
Practice Address - Phone:302-543-3219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE46-3211044302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization