MEDICARE: BRIANNA NICOLE 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	225400000X	Rehabilitation Practitioner	AT003789	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942896774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIANNA NICOLE JEFFERSON

Provider Business Mailing Address
First Line	:	8259 WICKER AVE
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8878
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3375 SPRING HILL PKWY SE APT 1034
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30080-6837
Country	:	US
Telephone Number	:	256-663-9172
Fax Number	:

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

Provider Enumeration Date	:	12/16/2020
Last Update Date	:	12/16/2020

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