Healthcare Provider Details

I. General information

NPI: 1477240760
Provider Name (Legal Business Name): S STAR JEFFRIES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 GRAND CANAL BLVD
STOCKTON CA
95207-8155
US

IV. Provider business mailing address

1811 GRAND CANAL BLVD
STOCKTON CA
95207-8155
US

V. Phone/Fax

Practice location:
  • Phone: 209-452-8996
  • Fax:
Mailing address:
  • Phone: 209-452-8996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: