MEDICARE: DEMETRIA YUSHONE JEFFERSON APRN, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	1179604	TX

General Provider Information

NPI Number	:	1053134056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRIA YUSHONE JEFFERSON APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	2626 S LOOP W STE 525
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2691
Country	:	US
Telephone Number	:	832-378-8282
Fax Number	:	832-834-6002

Provider Business Practice Location Address
First Line	:	2626 S LOOP W STE 525
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2691
Country	:	US
Telephone Number	:	832-378-8282
Fax Number	:	832-834-6002

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2024
Last Update Date	:	11/06/2024

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