Provider Demographics
NPI:1881580819
Name:JEFFERSON, LARRY D SR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:JEFFERSON
Suffix:SR
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 1:342 SYLVAN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39702-3014
Mailing Address - Country:US
Mailing Address - Phone:662-435-5300
Mailing Address - Fax:
Practice Address - Street 1:342 SYLVAN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-3014
Practice Address - Country:US
Practice Address - Phone:662-364-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801522422146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty