Healthcare Provider Details

I. General information

NPI: 1699696104
Provider Name (Legal Business Name): TIA JEFFERSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CADDO PL
NEW ORLEANS LA
70129-1053
US

IV. Provider business mailing address

11 CADDO PL
NEW ORLEANS LA
70129-1053
US

V. Phone/Fax

Practice location:
  • Phone: 504-810-9538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number206542
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: