Healthcare Provider Details

I. General information

NPI: 1306632344
Provider Name (Legal Business Name): MODUPE HARRIET AJISAFE M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF FAMILY MEDICINE 2500 N STATE ST
JACKSON MS
39216
US

IV. Provider business mailing address

1855 LAKELAND DR APT 415
JACKSON MS
39216-0005
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5426
  • Fax:
Mailing address:
  • Phone: 346-370-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT5940
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: