Provider Demographics
NPI:1205636909
Name:JEFFERY, VICKI L
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:JEFFERY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4339 BREEZEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1315
Mailing Address - Country:US
Mailing Address - Phone:937-554-8987
Mailing Address - Fax:
Practice Address - Street 1:4339 BREEZEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1315
Practice Address - Country:US
Practice Address - Phone:937-554-8987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHFNU1122172A00000X
OH172A00000X
343900000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)