Healthcare Provider Details

I. General information

NPI: 1609530856
Provider Name (Legal Business Name): KIMBERLY JEFFRIES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44871 ST. ANDREW'S CHURCH ROAD
CALIFORNIA MD
20619
US

IV. Provider business mailing address

44871 ST. ANDREWS CHURCH ROAD
CALIFORNIA MD
20619
US

V. Phone/Fax

Practice location:
  • Phone: 301-997-1300
  • Fax: 301-863-3368
Mailing address:
  • Phone: 301-997-1300
  • Fax: 301-863-3368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC2970
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: