Healthcare Provider Details

I. General information

NPI: 1114087186
Provider Name (Legal Business Name): KIMBERLY JANELL JEFFRIES OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 BIDDLE ST
WYANDOTTE MI
48192-4668
US

IV. Provider business mailing address

5122 IROQUOIS ST
DETROIT MI
48213-2985
US

V. Phone/Fax

Practice location:
  • Phone: 734-246-9033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201005664
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: