Provider Demographics
NPI: | 1821476094 |
---|---|
Name: | JEFFERY, THOMAS (APRN) |
Entity Type: | Individual |
Prefix: | |
First Name: | THOMAS |
Middle Name: | |
Last Name: | JEFFERY |
Suffix: | |
Gender: | M |
Credentials: | APRN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1746 SPLIT FORK DR |
Mailing Address - Street 2: | |
Mailing Address - City: | OLDSMAR |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 34677-2767 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-279-4781 |
Mailing Address - Fax: | 330-858-6832 |
Practice Address - Street 1: | 1746 SPLIT FORK DR |
Practice Address - Street 2: | |
Practice Address - City: | OLDSMAR |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34677-2767 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-279-4781 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2015-05-08 |
Last Update Date: | 2019-10-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | APRN9302885 | 364SP0808X |
FL | ARNP9302885 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Single Specialty |
No | 364SP0808X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psychiatric/Mental Health | Group - Single Specialty |