Provider Demographics
NPI:1396383881
Name:LEIFSON, JED
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:
Last Name:LEIFSON
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 1:28 N PALAFOX ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5626
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:
Practice Address - Street 1:3630 WILLOWCREEK RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5075
Practice Address - Country:US
Practice Address - Phone:219-364-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-15
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28255655A163W00000X
IN130221367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse