Healthcare Provider Details

I. General information

NPI: 1154398105
Provider Name (Legal Business Name): KELLEY VINCENT JEFFERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 01/09/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 TROTWOOD AVE
COLUMBIA TN
38401-4802
US

IV. Provider business mailing address

2717 EAST OAKLAND AVENUE
JOHNSON CITY TN
37601-1843
US

V. Phone/Fax

Practice location:
  • Phone: 931-359-4506
  • Fax: 931-490-7043
Mailing address:
  • Phone: 423-926-2358
  • Fax: 423-926-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD37199
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37199
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD37199
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: