Healthcare Provider Details

I. General information

NPI: 1295397297
Provider Name (Legal Business Name): JEFFERSON FAMILY CORPORATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S. JONES BLVD SUITE #3673
LAS VEGAS NV
89107
US

IV. Provider business mailing address

304 S. JONES BLVD. SUITE #3673
LAS VEGAS NV
89107
US

V. Phone/Fax

Practice location:
  • Phone: 702-684-3573
  • Fax: 702-548-6891
Mailing address:
  • Phone: 702-684-3573
  • Fax: 702-548-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANNIE MAE SPENCER
Title or Position: OWNER
Credential:
Phone: 702-684-3573