Healthcare Provider Details

I. General information

NPI: 1245860519
Provider Name (Legal Business Name): LA'SONYA JEFFERSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S RANCHO DR STE A
LAS VEGAS NV
89106-4849
US

IV. Provider business mailing address

630 S RANCHO DR
LAS VEGAS NV
89106-4873
US

V. Phone/Fax

Practice location:
  • Phone: 702-844-4580
  • Fax:
Mailing address:
  • Phone: 702-998-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1169P-S
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: