Provider Demographics
NPI:1700623311
Name:JEFFERSON, CONWAY II
Entity type:Individual
Prefix:
First Name:CONWAY
Middle Name:
Last Name:JEFFERSON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 MONTEO DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-2768
Mailing Address - Country:US
Mailing Address - Phone:317-619-9915
Mailing Address - Fax:
Practice Address - Street 1:6320 MONTEO DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-2768
Practice Address - Country:US
Practice Address - Phone:317-619-9915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-017483-13747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant