Provider Demographics
NPI:1275358806
Name:JEFFERSON, ETHAN SHAKEEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:SHAKEEL
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 I ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4367
Mailing Address - Country:US
Mailing Address - Phone:530-615-1615
Mailing Address - Fax:
Practice Address - Street 1:2725 I ST APT 2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4367
Practice Address - Country:US
Practice Address - Phone:530-615-1615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program