Healthcare Provider Details

I. General information

NPI: 1477289817
Provider Name (Legal Business Name): JEFFERSON STREET CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 JEFFERSON BLVD
LAFAYETTE LA
70501-7206
US

IV. Provider business mailing address

618 JEFFERSON BLVD
LAFAYETTE LA
70501-7206
US

V. Phone/Fax

Practice location:
  • Phone: 240-481-7672
  • Fax:
Mailing address:
  • Phone: 240-481-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BERYL WAYI YUFENYUY
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 240-481-7672