Provider Demographics
NPI:1831677194
Name:JEFFERSON, BRENDAN TAMAR
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:TAMAR
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 1:392 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-4139
Mailing Address - Country:US
Mailing Address - Phone:567-303-1171
Mailing Address - Fax:
Practice Address - Street 1:1033 LARCHWOOD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2424
Practice Address - Country:US
Practice Address - Phone:419-747-4122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician