Provider Demographics
NPI:1801253539
Name:KATRINA M. JEFFERSON
Entity type:Organization
Organization Name:KATRINA M. JEFFERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:740-622-7108
Mailing Address - Street 1:5930 MAHOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2210
Mailing Address - Country:US
Mailing Address - Phone:304-955-5111
Mailing Address - Fax:740-295-5372
Practice Address - Street 1:5930 MAHOOD DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2210
Practice Address - Country:US
Practice Address - Phone:304-955-5111
Practice Address - Fax:740-295-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty