Provider Demographics
NPI:1881912137
Name:JEFFERSON, NINA NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NINA
Middle Name:NICOLE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:766 HL ROSS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-367-6246
Practice Address - Fax:855-926-7383
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003323103TC0700X
AR15-06P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003100346AMedicaid
GA003100346AMedicaid