Provider Demographics
NPI:1174136139
Name:JEFFERSON, DAMECIA L
Entity type:Individual
Prefix:
First Name:DAMECIA
Middle Name:L
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 1:706 MANNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-3150
Mailing Address - Country:US
Mailing Address - Phone:504-206-8026
Mailing Address - Fax:
Practice Address - Street 1:706 MANNINGTON DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-3150
Practice Address - Country:US
Practice Address - Phone:504-206-8026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1009860164X00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse