Provider Demographics
NPI:1457809899
Name:JEFFERSON, ANGELA M (LMP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 W HOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-222-1132
Mailing Address - Fax:509-222-1133
Practice Address - Street 1:7106 W HOOD PLACE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-222-1132
Practice Address - Fax:509-222-1133
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60525407225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist