Healthcare Provider Details

I. General information

NPI: 1700779519
Provider Name (Legal Business Name): KEJAC VENTURES, PLLC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9390 MAYFIELD RD S
COLLIERVILLE TN
38017-3354
US

IV. Provider business mailing address

9390 MAYFIELD RD S
COLLIERVILLE TN
38017-3354
US

V. Phone/Fax

Practice location:
  • Phone: 901-849-4108
  • Fax:
Mailing address:
  • Phone: 901-849-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEELLON LOUISE MARTIN
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 901-849-4108