Provider Demographics
NPI:1497124291
Name:WILSON- JEFFERSON, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:WILSON- JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3854 PAPER BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-3342
Mailing Address - Country:US
Mailing Address - Phone:678-480-5054
Mailing Address - Fax:888-884-6471
Practice Address - Street 1:3854 PAPER BIRCH LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-3342
Practice Address - Country:US
Practice Address - Phone:678-480-5054
Practice Address - Fax:888-884-6471
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No332U00000XSuppliersHome Delivered Meals
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child