Provider Demographics
NPI:1104623990
Name:SANDERS-JEFFERSON, LERISSA DEANN
Entity type:Individual
Prefix:
First Name:LERISSA
Middle Name:DEANN
Last Name:SANDERS-JEFFERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 WINTER BAY LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-3330
Mailing Address - Country:US
Mailing Address - Phone:832-896-1779
Mailing Address - Fax:
Practice Address - Street 1:2122 WINTER BAY LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77088-3330
Practice Address - Country:US
Practice Address - Phone:832-896-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCWW2151171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WV0202XOther Service ProvidersContractorVehicle ModificationsGroup - Single Specialty