Provider Demographics
NPI:1396228573
Name:JEFFERSON, DERRICK
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
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 1:777 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-2239
Mailing Address - Country:US
Mailing Address - Phone:662-275-4718
Mailing Address - Fax:888-283-2894
Practice Address - Street 1:777 5TH ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-2239
Practice Address - Country:US
Practice Address - Phone:662-275-4718
Practice Address - Fax:888-283-2894
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)