Provider Demographics
NPI:1265729503
Name:JEFFERSON, KATHERINE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13890 BRADDOCK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2435
Mailing Address - Country:US
Mailing Address - Phone:540-720-2261
Mailing Address - Fax:540-720-5660
Practice Address - Street 1:2765 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 209
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-8331
Practice Address - Country:US
Practice Address - Phone:540-720-2261
Practice Address - Fax:540-720-5660
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22026210235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist