Provider Demographics
NPI:1669019527
Name:JEFFERSON, SHALET M
Entity Type:Individual
Prefix:
First Name:SHALET
Middle Name:M
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 1:17 RIDGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-2515
Mailing Address - Country:US
Mailing Address - Phone:609-310-9412
Mailing Address - Fax:
Practice Address - Street 1:101 ROUTE 130 S
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-2845
Practice Address - Country:US
Practice Address - Phone:609-310-9412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health