Basic Information
| Provider Information | |||||||||
| NPI: | 1891122982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6420 SYMPOSIUM WAY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018680516 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200023361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024424800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2013 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/02/2018 | ||||||||
| NPIReactivationDate: | 09/27/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | DC | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.