Provider Demographics
NPI:1134954191
Name:JEFFERSON, KHADIJAH KIANA
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:KIANA
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 1:7801 SAINT ANDREWS RD # B1
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7801 SAINT ANDREWS RD # B1
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2866
Practice Address - Country:US
Practice Address - Phone:803-240-9950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC54448164W00000X
372600000X, 3747P1801X, 376K00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376K00000XNursing Service Related ProvidersNurse's Aide