Healthcare Provider Details

I. General information

NPI: 1346654928
Provider Name (Legal Business Name): AYJEFFERSONENTERPRISES COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 06/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 CONNECTICUT AVE NW SUITE 1107
WASHINGTON DC
20008-3710
US

IV. Provider business mailing address

4501 CONNECTICUT AVE NW SUITE 1107
WASHINGTON DC
20008-3710
US

V. Phone/Fax

Practice location:
  • Phone: 202-630-9156
  • Fax: 202-478-0822
Mailing address:
  • Phone: 202-630-9156
  • Fax: 202-478-0822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number1016138-50078995
License Number StateDC

VIII. Authorized Official

Name: DR. ANTONETTE YVONNE JEFFERSON
Title or Position: CEO AND FOUNDER
Credential: J.D.
Phone: 202-630-9156