Provider Demographics
NPI:1477289817
Name:JEFFERSON STREET CLINIC LLC
Entity Type:Organization
Organization Name:JEFFERSON STREET CLINIC LLC
Other - Org Name:JEFFERSON STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BERYL
Authorized Official - Middle Name:WAYI
Authorized Official - Last Name:YUFENYUY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:240-481-7672
Mailing Address - Street 1:618 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-7206
Mailing Address - Country:US
Mailing Address - Phone:240-481-7672
Mailing Address - Fax:
Practice Address - Street 1:618 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7206
Practice Address - Country:US
Practice Address - Phone:240-481-7672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-27
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty