Provider Demographics
NPI:1619468048
Name:STJOHN, JEFFERY M
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:M
Last Name:STJOHN
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 1:415 N COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3627
Mailing Address - Country:US
Mailing Address - Phone:317-828-5125
Mailing Address - Fax:
Practice Address - Street 1:415 N COLORADO AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3627
Practice Address - Country:US
Practice Address - Phone:317-828-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8947455883172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver