Provider Demographics
NPI:1619221058
Name:JEFFERSON, SAMANTHA MATHIS
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MATHIS
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 1:3429 WESTMINISTER AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2913
Mailing Address - Country:US
Mailing Address - Phone:337-532-4600
Mailing Address - Fax:
Practice Address - Street 1:8404 STILLWOOD LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-6939
Practice Address - Country:US
Practice Address - Phone:337-532-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106802235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist