Healthcare Provider Details

I. General information

NPI: 1902829484
Provider Name (Legal Business Name): EDWARD KENNETH JEFFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 S GEORGE MASON DR 415N
FALLS CHURCH VA
22041-3758
US

IV. Provider business mailing address

3701 S GEORGE MASON DR 415N
FALLS CHURCH VA
22041-3758
US

V. Phone/Fax

Practice location:
  • Phone: 703-578-1068
  • Fax:
Mailing address:
  • Phone: 703-578-1068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101053378
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number8504
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number14706
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9900263
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20744
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number00019515
License Number StateAL
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number041143
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG13625
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD0000027749
License Number StateTN
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.11555R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: