Provider Demographics
NPI:1962263863
Name:JEFFERIES, TIWANA RICE (SUDRC #15127)
Entity type:Individual
Prefix:
First Name:TIWANA
Middle Name:RICE
Last Name:JEFFERIES
Suffix:
Gender:F
Credentials:SUDRC #15127
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 CAGLE CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-6329
Mailing Address - Country:US
Mailing Address - Phone:980-251-2485
Mailing Address - Fax:
Practice Address - Street 1:2408 CAGLE CT
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-6329
Practice Address - Country:US
Practice Address - Phone:980-251-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15127251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management