Healthcare Provider Details

I. General information

NPI: 1982169330
Provider Name (Legal Business Name): KALISHA SHEVOIN JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 HERBERT ST
SAINT AUGUSTINE FL
32084-4074
US

IV. Provider business mailing address

565 HERBERT ST
SAINT AUGUSTINE FL
32084-4074
US

V. Phone/Fax

Practice location:
  • Phone: 904-466-8993
  • Fax:
Mailing address:
  • Phone: 904-466-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberCNA23616
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: