Provider Demographics
NPI:1801228549
Name:JEFFERSON, JOHN L
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 W 119TH PL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2722
Mailing Address - Country:US
Mailing Address - Phone:310-612-3778
Mailing Address - Fax:310-676-1170
Practice Address - Street 1:4951 W 119TH PL
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2722
Practice Address - Country:US
Practice Address - Phone:310-612-3778
Practice Address - Fax:310-676-1170
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health