Provider Demographics
NPI:1982341889
Name:JEFFERSON, SHANIKA IESHA
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:IESHA
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 1:123 TIMBER CT
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2954
Mailing Address - Country:US
Mailing Address - Phone:434-426-1253
Mailing Address - Fax:
Practice Address - Street 1:123 TIMBER CT
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2954
Practice Address - Country:US
Practice Address - Phone:434-426-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-07-09
Deactivation Date:2022-05-23
Deactivation Code:
Reactivation Date:2022-06-24
Provider Licenses
StateLicense IDTaxonomies
VAE9J2E2T9246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy