Provider Demographics
NPI:1144539495
Name:JEFFERSON, MARIE ANTIONETTE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTIONETTE
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 1:98 HENDLEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5025
Mailing Address - Country:US
Mailing Address - Phone:707-527-0712
Mailing Address - Fax:707-527-6048
Practice Address - Street 1:98 HENDLEY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5025
Practice Address - Country:US
Practice Address - Phone:707-527-0712
Practice Address - Fax:707-527-6048
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6789OtherMEDICAL