Healthcare Provider Details

I. General information

NPI: 1912676636
Provider Name (Legal Business Name): ANGELICA DENISE JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4509 SAGEWOOD LN
CENTER POINT AL
35215-5856
US

IV. Provider business mailing address

4509 SAGEWOOD LN
CENTER POINT AL
35215-5856
US

V. Phone/Fax

Practice location:
  • Phone: 205-585-7286
  • Fax:
Mailing address:
  • Phone: 205-585-7286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225B00000X
TaxonomyPulmonary Function Technologist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number1074
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberM3B2H2C5
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: