Provider Demographics
NPI:1174023063
Name:JEFFERSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NNJ ENTERPRISE LLC
Mailing Address - Street 1:529 GRAYSON LN
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-3084
Mailing Address - Country:US
Mailing Address - Phone:254-289-4071
Mailing Address - Fax:830-433-4219
Practice Address - Street 1:529 GRAYSON LN
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-3084
Practice Address - Country:US
Practice Address - Phone:254-289-4071
Practice Address - Fax:830-433-4219
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care