Provider Demographics
NPI:1720486368
Name:JEFFERSON, SHAWNNEL JEWEL (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHAWNNEL
Middle Name:JEWEL
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 HOELTZER ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-1207
Mailing Address - Country:US
Mailing Address - Phone:585-520-4229
Mailing Address - Fax:
Practice Address - Street 1:65 HOELTZER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-1207
Practice Address - Country:US
Practice Address - Phone:585-520-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320385164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04042426Medicaid