Provider Demographics
NPI:1457750432
Name:JEFFERSON, LATASHA DEVONNE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:DEVONNE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 HWY 138 E
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7733
Mailing Address - Country:US
Mailing Address - Phone:470-377-2552
Mailing Address - Fax:770-385-9401
Practice Address - Street 1:105 N PARK TRL STE 300
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7432
Practice Address - Country:US
Practice Address - Phone:678-284-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily