Provider Demographics
NPI:1598246670
Name:JEFFERSON, ATHAN JOSEPH
Entity Type:Individual
Prefix:
First Name:ATHAN
Middle Name:JOSEPH
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14741 BRIGHTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70819-4012
Mailing Address - Country:US
Mailing Address - Phone:504-957-0001
Mailing Address - Fax:
Practice Address - Street 1:1097 S FLANNERY RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-6920
Practice Address - Country:US
Practice Address - Phone:504-957-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management