MEDICARE: ALEX CAMILLE JEFFERSON 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	163W00000X	Registered Nurse	2011017684	MO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2020001065	MO

General Provider Information

NPI Number	:	1588950919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX CAMILLE JEFFERSON PMHNP-BC

Provider Business Mailing Address
First Line	:	935 STATE ROUTE VV
Second Line	:
City	:	KENNETT
State	:	MO
Zip	:	63857-3822
Country	:	US
Telephone Number	:	573-888-5925
Fax Number	:

Provider Business Practice Location Address
First Line	:	935 STATE ROUTE VV
Second Line	:
City	:	KENNETT
State	:	MO
Zip	:	63857-3822
Country	:	US
Telephone Number	:	573-888-5925
Fax Number	:

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

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	01/16/2020

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