Provider Demographics
NPI:1043938962
Name:JEFFERSON, SHELDON
Entity type:Individual
Prefix:
First Name:SHELDON
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19046 BRUCE B DOWNS BLVD STE 177
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2434
Mailing Address - Country:US
Mailing Address - Phone:877-704-7464
Mailing Address - Fax:
Practice Address - Street 1:7613 MERCHANTVILLE CIR
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-2068
Practice Address - Country:US
Practice Address - Phone:813-810-9397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X, 224ZR0403X, 374U00000X
172A00000X, 372600000X
FL237233376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No224ZR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantDriving and Community Mobility
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1922761782Medicaid