Provider Demographics
NPI:1255934543
Name:JEFFERSON, CHERRY CHARLETTE (RN BSN)
Entity type:Individual
Prefix:
First Name:CHERRY
Middle Name:CHARLETTE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17919 OBELISK BAY DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-5626
Mailing Address - Country:US
Mailing Address - Phone:832-584-7114
Mailing Address - Fax:
Practice Address - Street 1:17919 OBELISK BAY DR
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5626
Practice Address - Country:US
Practice Address - Phone:832-584-7114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX905917163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice