Provider Demographics
NPI:1790087179
Name:JEFFERSON, CHARISA NICOLE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:CHARISA
Middle Name:NICOLE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:CHARISA
Other - Middle Name:NICOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:215 N MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4943
Mailing Address - Country:US
Mailing Address - Phone:803-775-9364
Mailing Address - Fax:803-773-6615
Practice Address - Street 1:2611 LIBERTY HILL RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-1871
Practice Address - Country:US
Practice Address - Phone:803-432-5323
Practice Address - Fax:803-713-3978
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical