Provider Demographics
NPI:1396760252
Name:JEFFERY, JESSIE (PA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:JEFFERY
Suffix:
Gender:F
Credentials:PA
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 882454
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-3554
Mailing Address - Country:US
Mailing Address - Phone:702-287-3813
Mailing Address - Fax:323-232-1924
Practice Address - Street 1:103 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1812
Practice Address - Country:US
Practice Address - Phone:310-412-3277
Practice Address - Fax:310-412-3223
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002402068Medicaid
NV002402068Medicaid
P32200Medicare UPIN