Healthcare Provider Details

I. General information

NPI: 1417801648
Provider Name (Legal Business Name): JEFFERSON HOMES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 W 82ND ST
LOS ANGELES CA
90047-2620
US

IV. Provider business mailing address

6201 W 87TH ST # 2681
WESTCHESTER CA
90045-3901
US

V. Phone/Fax

Practice location:
  • Phone: 818-963-0079
  • Fax:
Mailing address:
  • Phone: 310-649-3919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CORNELL JEFFERSON
Title or Position: MANAGING MEMBER
Credential:
Phone: 818-963-0079