Provider Demographics
NPI:1538336193
Name:JEFFERSON, ELNORA S
Entity type:Individual
Prefix:
First Name:ELNORA
Middle Name:S
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 1:2927 WILCOX AVE
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2247
Mailing Address - Country:US
Mailing Address - Phone:615-478-9287
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR STE 120
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:844-247-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37040192355S0801X
IL18-56015106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant