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General NPI Number Information
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NPI Number | 1801692462
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Entity Type | Individual
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Provider Name | WENDALL KEITH JEFFERSON
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Gender | Male
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Dates
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Enumeration Date | 02/24/2025
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Last Update Date | 03/22/2025
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Provider Practice Location Address
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Address Line | 1719 12TH ST
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City | PHENIX CITY
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State | AL
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Zip | 36867-6044
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Country | US
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Telephone | 404-307-5251
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Fax |
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Provider Business Mailing Address
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Address Line | 1719 12TH ST
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City | PHENIX CITY
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State | AL
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Zip | 36867-6044
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Country | US
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Telephone | 404-307-5251
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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 | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State | AL
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