Provider Demographics
NPI:1568252294
Name:JEFFERSON, MYNAE DIONNA
Entity type:Individual
Prefix:
First Name:MYNAE
Middle Name:DIONNA
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 1:843 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-2801
Mailing Address - Country:US
Mailing Address - Phone:219-888-9468
Mailing Address - Fax:
Practice Address - Street 1:843 E 49TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-2801
Practice Address - Country:US
Practice Address - Phone:219-888-9468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician