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General NPI Number Information
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NPI Number | 1326121286
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Entity Type | Individual
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Provider Name | GLENN E JEFFERSON JR. MD
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 03/08/2016
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Provider Practice Location Address
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Address Line | 2315 8TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-7301
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Country | US
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Telephone | 208-746-1383
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Fax | 208-746-6348
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Provider Business Mailing Address
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Address Line | 2315 8TH ST
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City | LEWISTON
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State | ID
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Zip | 83501-7301
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Country | US
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Telephone | 208-746-1383
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Fax | 208-746-6348
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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 | M4593
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD00025241
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License Number State | WA
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