Provider Demographics
NPI:1609357953
Name:JEFFERS, KEVEN WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVEN
Middle Name:WAYNE
Last Name:JEFFERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-5771
Mailing Address - Fax:
Practice Address - Street 1:550 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2343
Practice Address - Country:US
Practice Address - Phone:423-784-5771
Practice Address - Fax:423-455-0380
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2407363A00000X
TN3646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2407OtherSTATE LICENSE
TN3646OtherSTATE LICENSE
KY7100571470Medicaid
TNQ045895Medicaid
TNQ045895Medicaid