Provider Demographics
NPI:1396004263
Name:JEFFERSON, CORNELL LEON
Entity Type:Individual
Prefix:
First Name:CORNELL
Middle Name:LEON
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 1:4915 E RUSSELL RD APT 125
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2387
Mailing Address - Country:US
Mailing Address - Phone:702-788-0091
Mailing Address - Fax:
Practice Address - Street 1:4915 E RUSSELL RD APT 125
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2387
Practice Address - Country:US
Practice Address - Phone:702-788-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV320800000X320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness