Healthcare Provider Details

I. General information

NPI: 1427673367
Provider Name (Legal Business Name): KEZIA E COLEMAN PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 BONHOMME AVE STE 1800
CLAYTON MO
63105-1931
US

IV. Provider business mailing address

7711 BONHOMME AVE STE 720
CLAYTON MO
63105-1908
US

V. Phone/Fax

Practice location:
  • Phone: 314-472-3091
  • Fax:
Mailing address:
  • Phone: 314-472-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. KEZIA JACKSON
Title or Position: OWNER
Credential: PSYD
Phone: 314-472-3091