Basic Information
| Provider Information | |||||||||
| NPI: | 1669622072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LVN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTGOMERY | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LVN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 490 W 14TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908132943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625918701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 490 W 14TH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908132943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5625918701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2008 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | VN185520 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.