Provider Demographics
NPI:1629557921
Name:HALL IV, JEFFERSON CEMORE IV
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:CEMORE
Last Name:HALL IV
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CAMINO DEL SOL STE 1
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-3725
Mailing Address - Country:US
Mailing Address - Phone:805-604-5437
Mailing Address - Fax:
Practice Address - Street 1:1500 CAMINO DEL SOL STE 1
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3725
Practice Address - Country:US
Practice Address - Phone:805-604-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
CA225400000X
CA1179231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherINTERNSHIP