Healthcare Provider Details

I. General information

NPI: 1437809332
Provider Name (Legal Business Name): KATHLEEN LILLY JEFFRIES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 RUSSELL ST
DETROIT MI
48211-2500
US

IV. Provider business mailing address

5301 RUSSELL ST
DETROIT MI
48211-2500
US

V. Phone/Fax

Practice location:
  • Phone: 313-224-2247
  • Fax:
Mailing address:
  • Phone: 313-224-2247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001342205
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-180664
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number5081619
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.1001261-NP
License Number StateCO
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704406562
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: