Provider Demographics
NPI:1811560907
Name:JEFFERSON, RACQUEL MONIQUE
Entity Type:Individual
Prefix:
First Name:RACQUEL
Middle Name:MONIQUE
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 1:21 N PADDOCK ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2618
Mailing Address - Country:US
Mailing Address - Phone:248-818-1755
Mailing Address - Fax:
Practice Address - Street 1:817 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1570
Practice Address - Country:US
Practice Address - Phone:248-818-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide