Provider Demographics
NPI:1295220861
Name:JEFFERS, IDA M (LVN)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:M
Last Name:JEFFERS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:M
Other - Last Name:KENNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:548 ARBORS CIR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:TX
Mailing Address - Zip Code:78621-5574
Mailing Address - Country:US
Mailing Address - Phone:410-562-8238
Mailing Address - Fax:
Practice Address - Street 1:6600 E BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-7537
Practice Address - Country:US
Practice Address - Phone:512-445-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84568164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse