Provider Demographics
NPI:1912362286
Name:JEFFERS, JAY
Entity type:Individual
Prefix:MR
First Name:JAY
Middle Name:
Last Name:JEFFERS
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 1:5366 SANTA LUPE AVE
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-3646
Mailing Address - Country:US
Mailing Address - Phone:775-626-5755
Mailing Address - Fax:775-626-5755
Practice Address - Street 1:5366 SANTA LUPE AVE
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-3646
Practice Address - Country:US
Practice Address - Phone:775-626-5755
Practice Address - Fax:775-626-5755
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005041726Medicaid