Provider Demographics
NPI:1346974177
Name:JEFFERS, SAMANTHA RENEE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:JEFFERS
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 1:40 WEBSTER MANOR DR APT 1
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2099
Mailing Address - Country:US
Mailing Address - Phone:585-710-3237
Mailing Address - Fax:
Practice Address - Street 1:40 WEBSTER MANOR DR APT 1
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2099
Practice Address - Country:US
Practice Address - Phone:585-710-3237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYAEC-22-06231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty