Provider Demographics
NPI:1457969875
Name:JEFFERSON, ELIZABETH CHEVON
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHEVON
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CHEVON
Other - Last Name:JEFFERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2410 ARLINE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5539
Mailing Address - Country:US
Mailing Address - Phone:405-697-8133
Mailing Address - Fax:
Practice Address - Street 1:4103 S YALE AVE STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6002
Practice Address - Country:US
Practice Address - Phone:918-687-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator