Provider Demographics
NPI:1275199747
Name:JEFFERSON, MICHELLE D
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
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 1:233 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-4204
Mailing Address - Country:US
Mailing Address - Phone:860-229-4830
Mailing Address - Fax:860-229-2715
Practice Address - Street 1:233 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-4204
Practice Address - Country:US
Practice Address - Phone:860-229-4830
Practice Address - Fax:860-229-2715
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004368101YM0800X
CT112821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1174624423Medicaid