Provider Demographics
NPI:1275848996
Name:JEFFERSON, WILLIE L
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:L
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:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:WHITE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32096
Mailing Address - Country:US
Mailing Address - Phone:386-397-1879
Mailing Address - Fax:
Practice Address - Street 1:19351 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:WHITE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32096
Practice Address - Country:US
Practice Address - Phone:386-397-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)