MEDICARE: QUANETTA JEFFERSON

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	101YP2500X	Professional Counselor	7244	SC
2	106S00000X	Behavior Technician	17-32172	SC

General Provider Information

NPI Number	:	1548766819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUANETTA JEFFERSON

Provider Business Mailing Address
First Line	:	200 SPRINGTREE DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-8614
Country	:	US
Telephone Number	:	803-722-4975
Fax Number	:	803-722-6018

Provider Business Practice Location Address
First Line	:	200 SPRINGTREE DR
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-8614
Country	:	US
Telephone Number	:	803-722-4975
Fax Number	:	903-722-6018

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

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	09/30/2021

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Directions to “ QUANETTA JEFFERSON ” Practice Location

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