Active NPI
Nina Nicole Jefferson, PSY.D.
- Clinical Psychologist
- Monticello, AR
National Provider Identifier
1881912137
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 15-06P
- Practice address
- 766 HL Ross Dr
Monticello, AR 71655 - Phone
- (870) 367-6246
- Fax
- (855) 926-7383
- NPI assigned
- May 12, 2010
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY003323 | GA | |
| Clinical Psychologist | 103TC0700X | 15-06P | AR | Primary |
Addresses
Primary practice location
766 HL Ross Dr
Monticello, AR 71655
Mailing address
PO Box 509
Dermott, AR 71638
Phone (870) 538-5414
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 003100346A | Medicaid | GA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 15-06P | AR | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mainline Health Systems Inc | Past | Accepting new patients | |
| Jefferson Psychological Solutions, LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Community/Behavioral Health Agency
- Douglasville, GA
- NPI 1447579925
-
- Federally Qualified Health Center (FQHC)
- Monticello, AR
- NPI 1205163540
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1273622400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1658361600000",
"number": "1881912137",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 509",
"city": "DERMOTT",
"state": "AR",
"postal_code": "71638",
"telephone_number": "870-538-5414",
"fax_number": "870-538-5412"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "766 HL ROSS DR",
"city": "MONTICELLO",
"state": "AR",
"postal_code": "71655",
"telephone_number": "870-367-6246",
"fax_number": "855-926-7383"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JEFFERSON",
"first_name": "NINA",
"middle_name": "NICOLE",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2010-05-12",
"last_updated": "2022-07-21",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "GA",
"license": "PSY003323",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "AR",
"license": "15-06P",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "003100346A",
"state": "GA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Monticello, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.