Provider Demographics
NPI:1124407127
Name:JEFFERSON, DOMONIQUE
Entity Type:Individual
Prefix:MS
First Name:DOMONIQUE
Middle Name:
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 1:13226 RUSTIC GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-0104
Mailing Address - Country:US
Mailing Address - Phone:832-288-1931
Mailing Address - Fax:
Practice Address - Street 1:13226 RUSTIC GARDEN DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-0104
Practice Address - Country:US
Practice Address - Phone:832-288-1931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services