Provider Demographics
NPI:1770954539
Name:JEFSON, JUSTINE
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:JEFSON
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 1:8160 COUNTY ROAD 64 APT 1523
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-6188
Mailing Address - Country:US
Mailing Address - Phone:251-234-4307
Mailing Address - Fax:
Practice Address - Street 1:10040 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5499
Practice Address - Country:US
Practice Address - Phone:850-474-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3652224Z00000X
FLOTA14374224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant