Basic Information
| Provider Information | |||||||||
| NPI: | 1861788085 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10430 RAY RD | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320818813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046718329 | ||||||||
| FaxNumber: | 9048249983 | ||||||||
| Practice Location | |||||||||
| Address1: | 10430 RAY RD | ||||||||
| Address2: | |||||||||
| City: | PONTE VEDRA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320818813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046718329 | ||||||||
| FaxNumber: | 9048249983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TRN 16281 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME118129 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME 118129 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.