Healthcare Provider Details

I. General information

NPI: 1649640087
Provider Name (Legal Business Name): JESSICA JEFFERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W BROWARD BLVD SUITE 100
FORT LAUDERDALE FL
33312-1018
US

IV. Provider business mailing address

8380 W STATE ROAD 84
DAVIE FL
33324-4546
US

V. Phone/Fax

Practice location:
  • Phone: 954-587-1008
  • Fax:
Mailing address:
  • Phone: 954-225-9851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: