Provider Demographics
NPI:1619599248
Name:JEFFERSON, JACQUELINE DANIELLE
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:DANIELLE
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 1:4326 W CHEYENNE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-2484
Mailing Address - Country:US
Mailing Address - Phone:702-636-4700
Mailing Address - Fax:702-636-1952
Practice Address - Street 1:4326 W CHEYENNE AVE STE 100
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2484
Practice Address - Country:US
Practice Address - Phone:702-636-4700
Practice Address - Fax:702-636-1952
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide