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General NPI Number Information
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NPI Number | 1306632344
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Entity Type | Individual
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Provider Name | MODUPE HARRIET AJISAFE M.D
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Gender | Female
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Dates
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Enumeration Date | 04/16/2025
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Last Update Date | 11/05/2025
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Provider Practice Location Address
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Address Line | DEPARTMENT OF FAMILY MEDICINE 2500 N STATE ST
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City | JACKSON
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State | MS
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Zip | 39216
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Country | US
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Telephone | 601-984-5426
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Fax |
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Provider Business Mailing Address
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Address Line | 1855 LAKELAND DR APT 415
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City | JACKSON
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State | MS
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Zip | 39216-0005
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Country | US
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Telephone | 346-370-2417
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | T5940
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License Number State | MS
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