Provider Demographics
NPI:1578941894
Name:JEFFERSON, LUTISHA
Entity Type:Individual
Prefix:
First Name:LUTISHA
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 1:333 N LA GRANGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:708-698-5090
Practice Address - Street 1:333 N LA GRANGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5646
Practice Address - Country:US
Practice Address - Phone:708-995-3680
Practice Address - Fax:708-698-5090
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor