Provider Demographics
NPI:1952182123
Name:JEFFERSON, JORESA DIONDRA
Entity Type:Individual
Prefix:
First Name:JORESA
Middle Name:DIONDRA
Last Name:JEFFERSON
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 1:18088 SE MARKET ST APT 112
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5056
Mailing Address - Country:US
Mailing Address - Phone:971-865-1907
Mailing Address - Fax:
Practice Address - Street 1:3231 SE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2248
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-CRM-1585175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist