Provider Demographics
NPI:1669351979
Name:JEFFERSON, CASANDRA DENISE
Entity type:Individual
Prefix:
First Name:CASANDRA
Middle Name:DENISE
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 1:3452 INWOOD CIR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5518
Mailing Address - Country:US
Mailing Address - Phone:904-955-9600
Mailing Address - Fax:
Practice Address - Street 1:3452 INWOOD CIR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5518
Practice Address - Country:US
Practice Address - Phone:904-955-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X
FLJ162104639020172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
No372600000XNursing Service Related ProvidersAdult Companion