Provider Demographics
NPI:1194221242
Name:JEFFERSON, SHENITA R
Entity Type:Individual
Prefix:
First Name:SHENITA
Middle Name:R
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 1:612 LAKESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6600
Mailing Address - Country:US
Mailing Address - Phone:405-822-3995
Mailing Address - Fax:
Practice Address - Street 1:700 PARKHURST TER
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5062
Practice Address - Country:US
Practice Address - Phone:405-822-3995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist