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General NPI Number Information
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NPI Number | 1427673367
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Entity Type | Organization
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Legal Business Name | KEZIA E COLEMAN PSYD LLC
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Dates
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Enumeration Date | 06/16/2020
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Last Update Date | 09/21/2023
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Provider Practice Location Address
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Address Line | 7777 BONHOMME AVE STE 1800
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City | CLAYTON
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State | MO
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Zip | 63105-1931
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Country | US
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Telephone | 314-472-3091
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Fax |
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Provider Business Mailing Address
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Address Line | 7711 BONHOMME AVE STE 720
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City | CLAYTON
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State | MO
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Zip | 63105-1908
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Country | US
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Telephone | 314-472-3091
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEZIA JACKSON
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Credential | PSYD
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Telephone | 314-472-3091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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