Basic Information
| Provider Information | |||||||||
| NPI: | 1609357953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERS | ||||||||
| FirstName: | KEVEN | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377622154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237845771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 SUNSET TRL | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377622343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237845771 | ||||||||
| FaxNumber: | 4234550380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2018 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2407 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3646 | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA2407 | 01 | KY | STATE LICENSE | OTHER | 3646 | 01 | TN | STATE LICENSE | OTHER | MJ5493731 | 01 | TN | DEA | OTHER | 7100571470 | 05 | KY | MEDICAID | Q045895 | 05 | TN | MEDICAID |