Provider Demographics
NPI:1659876795
Name:JEFFERSON-DAVIS, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:JEFFERSON-DAVIS
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 1:341 MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1200
Mailing Address - Country:US
Mailing Address - Phone:434-799-6400
Mailing Address - Fax:
Practice Address - Street 1:341 MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1200
Practice Address - Country:US
Practice Address - Phone:434-799-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0600681103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool