Provider Demographics
NPI:1710288246
Name:JEFFERSON, SONNIE L
Entity Type:Individual
Prefix:
First Name:SONNIE
Middle Name:L
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 1:409 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:HANSEN
Mailing Address - State:ID
Mailing Address - Zip Code:83334-4917
Mailing Address - Country:US
Mailing Address - Phone:208-423-5779
Mailing Address - Fax:
Practice Address - Street 1:409 1ST ST E
Practice Address - Street 2:
Practice Address - City:HANSEN
Practice Address - State:ID
Practice Address - Zip Code:83334-4917
Practice Address - Country:US
Practice Address - Phone:208-423-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker