Provider Demographics
NPI:1053899336
Name:JEFFERY, MELISSA ANNE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:JEFFERY
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 1:8182 OAKBRIAR CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7937
Mailing Address - Country:US
Mailing Address - Phone:916-890-5225
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY SUITE 1300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820
Practice Address - Country:US
Practice Address - Phone:916-890-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1003004172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11521FOtherMEDI-CAL
CAZZR11521FMedicaid