Provider Demographics
NPI:1891166310
Name:JEFFERSON, TERRY
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:
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 1:40 SHAREN PL
Mailing Address - Street 2:
Mailing Address - City:WESTWEGO
Mailing Address - State:LA
Mailing Address - Zip Code:70094-5509
Mailing Address - Country:US
Mailing Address - Phone:504-353-2029
Mailing Address - Fax:
Practice Address - Street 1:3801 CANAL ST STE 325
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6059
Practice Address - Country:US
Practice Address - Phone:504-483-3558
Practice Address - Fax:504-525-4483
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LA14959104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker