Provider Demographics
NPI:1194976076
Name:JEFFERSON, DARLISHIA LE'SHAWN (AUD)
Entity type:Individual
Prefix:
First Name:DARLISHIA
Middle Name:LE'SHAWN
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BALDWIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3370
Practice Address - Country:US
Practice Address - Phone:704-316-1900
Practice Address - Fax:704-316-1924
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10631235Z00000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist