Provider Demographics
NPI:1851831911
Name:ADISAM, JEFFREY CHONAWORAH
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CHONAWORAH
Last Name:ADISAM
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 1:1087 E INDEPENDENCE ST
Mailing Address - Street 2:306
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-1434
Mailing Address - Country:US
Mailing Address - Phone:720-277-7404
Mailing Address - Fax:
Practice Address - Street 1:1087 E INDEPENDENCE ST
Practice Address - Street 2:306
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-1434
Practice Address - Country:US
Practice Address - Phone:720-277-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities