MEDICARE: ATHAN JOSEPH JEFFERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management		LA

General Provider Information

NPI Number	:	1598246670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ATHAN JOSEPH JEFFERSON

Provider Business Mailing Address
First Line	:	14741 BRIGHTVIEW CT
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70819-4012
Country	:	US
Telephone Number	:	504-957-0001
Fax Number	:

Provider Business Practice Location Address
First Line	:	1097 S FLANNERY RD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70815-6920
Country	:	US
Telephone Number	:	504-957-0001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	08/27/2018

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