Provider Demographics
NPI:1588321830
Name:JEFFERSON, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 US 31W BYP
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2577
Mailing Address - Country:US
Mailing Address - Phone:270-777-6321
Mailing Address - Fax:
Practice Address - Street 1:1254 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2577
Practice Address - Country:US
Practice Address - Phone:270-777-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY332BC3200X, 335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier