Provider Demographics
NPI:1225366487
Name:JEFFERSON, RUNNIE DEWAYNE
Entity Type:Individual
Prefix:MR
First Name:RUNNIE
Middle Name:DEWAYNE
Last Name:JEFFERSON
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 1:996 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7724
Mailing Address - Country:US
Mailing Address - Phone:901-332-0402
Mailing Address - Fax:901-332-0402
Practice Address - Street 1:996 PALMER RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7724
Practice Address - Country:US
Practice Address - Phone:980-133-2040
Practice Address - Fax:901-332-0402
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN52362989172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver