Provider Demographics
NPI:1932601721
Name:JEFFERSON, TINA ORA (BACHELORS DEGREE)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ORA
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:BACHELORS DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 S 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-1731
Mailing Address - Country:US
Mailing Address - Phone:773-397-5182
Mailing Address - Fax:
Practice Address - Street 1:1422 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1731
Practice Address - Country:US
Practice Address - Phone:773-397-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist