Provider Demographics
NPI:1760155543
Name:JEFFERSON, TIERRHA C
Entity Type:Individual
Prefix:MISS
First Name:TIERRHA
Middle Name:C
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 1:929 W HILLCREST DR APT 2
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1655
Mailing Address - Country:US
Mailing Address - Phone:224-400-7257
Mailing Address - Fax:
Practice Address - Street 1:929 W HILLCREST DR APT 2
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1655
Practice Address - Country:US
Practice Address - Phone:224-400-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL081077927Medicaid