1245236421 NPI number — JOE MAC JEFFERS ED.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245236421 NPI number — JOE MAC JEFFERS ED.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JEFFERS
Provider First Name:
JOE
Provider Middle Name:
MAC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ED.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245236421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1517 DARLENE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANGELO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76904-9005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-942-8191
Provider Business Mailing Address Fax Number:
325-942-7532

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3471 KNICKERBOCKER RD
Provider Second Line Business Practice Location Address:
STE 508
Provider Business Practice Location Address City Name:
SAN ANGELO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76904-8826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-942-7531
Provider Business Practice Location Address Fax Number:
325-942-7532
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  21733 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130095 . This is a "MHN/HMC CLAIMS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 117880 . This is a "SUPERIOR HEALTHPLAN NETWO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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