Provider Demographics
NPI:1225462823
Name:JEFFERSON, JEVON
Entity Type:Individual
Prefix:
First Name:JEVON
Middle Name:
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 1:6536 POINT BREAK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-1245
Mailing Address - Country:US
Mailing Address - Phone:702-624-7012
Mailing Address - Fax:
Practice Address - Street 1:5135 CAMINO AL NORTE STE 259
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2419
Practice Address - Country:US
Practice Address - Phone:702-806-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker