Provider Demographics
NPI:1497167084
Name:JEFFERSON-FITTS, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:JEFFERSON-FITTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 S KOLIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-1138
Mailing Address - Country:US
Mailing Address - Phone:773-972-6599
Mailing Address - Fax:
Practice Address - Street 1:1228 S KOLIN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-1138
Practice Address - Country:US
Practice Address - Phone:773-972-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILJ16281270816222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist