Healthcare Provider Details

I. General information

NPI: 1780028829
Provider Name (Legal Business Name): KETURAH WILLIAMS JEFFRIES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. KETURAH WILLIAMS BENNETT

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 248-990-3572
  • Fax:
Mailing address:
  • Phone: 313-576-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number4301103849
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: