Provider Demographics
NPI:1548766819
Name:JEFFERSON, QUANETTA
Entity Type:Individual
Prefix:
First Name:QUANETTA
Middle Name:
Last Name:JEFFERSON
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 1:200 SPRINGTREE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-8614
Mailing Address - Country:US
Mailing Address - Phone:803-722-4975
Mailing Address - Fax:803-722-6018
Practice Address - Street 1:200 SPRINGTREE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-8614
Practice Address - Country:US
Practice Address - Phone:803-722-4975
Practice Address - Fax:903-722-6018
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7244101YP2500X
SC17-32172106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician