Provider Demographics
NPI:1689136624
Name:SHAREEF-JEFFERSON, RAUSHANAH TAHERRAH (RDH, IBCLC)
Entity Type:Individual
Prefix:
First Name:RAUSHANAH
Middle Name:TAHERRAH
Last Name:SHAREEF-JEFFERSON
Suffix:
Gender:F
Credentials:RDH, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 RIDGECREST RD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:972-795-7422
Mailing Address - Fax:
Practice Address - Street 1:831 RIDGECREST RD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:972-795-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-108268174N00000X
TX13480124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN