Provider Demographics
NPI:1407310337
Name:JEFFERSON, SHANITA LEANNA (RKT)
Entity Type:Individual
Prefix:
First Name:SHANITA
Middle Name:LEANNA
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 FESTIVAL PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-4449
Mailing Address - Country:US
Mailing Address - Phone:804-621-5462
Mailing Address - Fax:
Practice Address - Street 1:3600 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-4915
Practice Address - Country:US
Practice Address - Phone:804-585-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist