Healthcare Provider Details

I. General information

NPI: 1730685934
Provider Name (Legal Business Name): SHAQUILLE JEFFERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E WASHINGTON ST STE 150
MEDINA OH
44256-3336
US

IV. Provider business mailing address

801 E. WASINGTON ST. SUITE 150
MEDINA OH
44256-3336
US

V. Phone/Fax

Practice location:
  • Phone: 330-264-3232
  • Fax:
Mailing address:
  • Phone: 330-722-1069
  • Fax: 330-764-9712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: