MEDICARE: KYLAYHA D JEFFERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	103T00000X	Psychologist	6362009617	MI

General Provider Information

NPI Number	:	1407428675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLAYHA D JEFFERSON

Provider Business Mailing Address
First Line	:	17940 FARMINGTON RD STE 302
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48152-3159
Country	:	US
Telephone Number	:	810-877-5919
Fax Number	:

Provider Business Practice Location Address
First Line	:	4036 BENNETT LAKE RD APT SUITE
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-8709
Country	:	US
Telephone Number	:	810-877-5919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2021
Last Update Date	:	05/30/2025

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Directions to “ KYLAYHA D JEFFERSON ” Practice Location

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