Healthcare Provider Details

I. General information

NPI: 1265165039
Provider Name (Legal Business Name): MR. LAWERENCE JOSEPH JEFFERSON II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WAYNE PL SE
WASHINGTON DC
20032-6119
US

IV. Provider business mailing address

10317 TULIP TREE DR
BOWIE MD
20721-3704
US

V. Phone/Fax

Practice location:
  • Phone: 202-768-2646
  • Fax:
Mailing address:
  • Phone: 240-602-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT24909
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: