Provider Demographics
NPI:1700232410
Name:JEFFERSON, CHERYL MARIE
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:MARIE
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 1:222 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-1451
Mailing Address - Country:US
Mailing Address - Phone:419-341-6465
Mailing Address - Fax:
Practice Address - Street 1:136 1/2 W WATER ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-1379
Practice Address - Country:US
Practice Address - Phone:419-559-9418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS11010621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical