Provider Demographics
NPI:1265983670
Name:JEFFERSON, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
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 1:915 EASTHAM CT APT T3
Mailing Address - Street 2:CROFTON
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1043
Mailing Address - Country:US
Mailing Address - Phone:240-535-4818
Mailing Address - Fax:
Practice Address - Street 1:2670 CRAIN HWY STE 206
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2816
Practice Address - Country:US
Practice Address - Phone:240-535-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD195621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical