Provider Demographics
NPI:1417991035
Name:JEFFERSON FAMILY PRACTICE
Entity Type:Organization
Organization Name:JEFFERSON FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:HELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-735-1199
Mailing Address - Street 1:9647 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1512
Mailing Address - Country:US
Mailing Address - Phone:210-735-5225
Mailing Address - Fax:210-735-3207
Practice Address - Street 1:9647 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1512
Practice Address - Country:US
Practice Address - Phone:210-735-5225
Practice Address - Fax:210-735-3207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083854201Medicaid
TX00L83GMedicare PIN
TX083854201Medicaid