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General NPI Number Information
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NPI Number | 1275358806
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Entity Type | Individual
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Provider Name | ETHAN SHAKEEL JEFFERSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/19/2024
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 280 SIERRA COLLEGE DR STE 207
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City | GRASS VALLEY
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State | CA
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Zip | 95945-5769
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Country | US
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Telephone | 530-477-7390
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Fax | 530-477-7389
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Provider Business Mailing Address
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Address Line | 2725 I ST APT 2
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City | SACRAMENTO
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State | CA
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Zip | 95816-4367
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Country | US
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Telephone | 530-615-1615
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 67370
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License Number State | CA
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