Healthcare Provider Details

I. General information

NPI: 1982524161
Provider Name (Legal Business Name): MR. KENNY JEFFERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7956 SURREY DR
ROMULUS MI
48174-6332
US

IV. Provider business mailing address

7956 SURREY DR
ROMULUS MI
48174-6332
US

V. Phone/Fax

Practice location:
  • Phone: 404-964-7776
  • Fax:
Mailing address:
  • Phone: 404-964-7776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704294272
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: