Provider Demographics
NPI:1598107591
Name:JEFFERSON, PHUNG HORTON
Entity Type:Individual
Prefix:MS
First Name:PHUNG
Middle Name:HORTON
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 1:1448 E CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1705
Mailing Address - Country:US
Mailing Address - Phone:702-401-3632
Mailing Address - Fax:702-382-4071
Practice Address - Street 1:1448 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1705
Practice Address - Country:US
Practice Address - Phone:702-401-3632
Practice Address - Fax:702-382-4071
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner