Provider Demographics
NPI:1730957176
Name:JEFFERSON, QUIANA MICHELLE
Entity type:Individual
Prefix:
First Name:QUIANA
Middle Name:MICHELLE
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 1:123 PARK ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9079
Mailing Address - Country:US
Mailing Address - Phone:773-653-7890
Mailing Address - Fax:
Practice Address - Street 1:579 W NORTH AVE STE 206
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2144
Practice Address - Country:US
Practice Address - Phone:630-384-9499
Practice Address - Fax:630-324-4606
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150110997104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker