Provider Demographics
NPI:1770183709
Name:WHITE, JEFFERY (MASTER BARBER)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MASTER BARBER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-4633
Mailing Address - Country:US
Mailing Address - Phone:478-812-8488
Mailing Address - Fax:
Practice Address - Street 1:1381 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4633
Practice Address - Country:US
Practice Address - Phone:478-812-8488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA156FX1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1900XEye and Vision Services ProvidersTechnician/TechnologistOrthoptist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1111111111111111111Medicaid