Provider Demographics
NPI:1609537703
Name:JEFFERSON, MERISSA
Entity Type:Individual
Prefix:
First Name:MERISSA
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 1:2201 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2962
Mailing Address - Country:US
Mailing Address - Phone:253-334-4390
Mailing Address - Fax:
Practice Address - Street 1:2201 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2962
Practice Address - Country:US
Practice Address - Phone:253-334-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-01
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician