Provider Demographics
NPI:1023709987
Name:JEFFERSON, KRISTY (LPN)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4973 W NEW SHADOW WAY
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85658-4293
Mailing Address - Country:US
Mailing Address - Phone:217-440-7491
Mailing Address - Fax:
Practice Address - Street 1:102 N PLUMER AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-5906
Practice Address - Country:US
Practice Address - Phone:520-225-3284
Practice Address - Fax:520-225-3201
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ284195405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional