Basic Information
| Provider Information | |||||||||
| NPI: | 1730685934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | SHAQUILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 E. WASINGTON ST. | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307221069 | ||||||||
| FaxNumber: | 3307649712 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E WASHINGTON ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.