Provider Demographics
NPI:1740791870
Name:JEFFERSON, CAMMERON ELIJAH (QBA)
Entity Type:Individual
Prefix:MR
First Name:CAMMERON
Middle Name:ELIJAH
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3770 FAMIGLIA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3454
Mailing Address - Country:US
Mailing Address - Phone:702-351-6572
Mailing Address - Fax:
Practice Address - Street 1:1516 E TROPICANA AVE STE 280
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8343
Practice Address - Country:US
Practice Address - Phone:702-586-9674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health