MEDICARE: KRYSTLE MONIQUE' 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	237700000X	Hearing Instrument Specialist	3502013279

General Provider Information

NPI Number	:	1770341851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTLE MONIQUE' JEFFERSON

Provider Business Mailing Address
First Line	:	1482 SAUTER ST
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49442-5488
Country	:	US
Telephone Number	:	816-786-9649
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 E SHERMAN BLVD
Second Line	:
City	:	NORTON SHORES
State	:	MI
Zip	:	49444-1809
Country	:	US
Telephone Number	:	231-733-2008
Fax Number	:

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

Provider Enumeration Date	:	03/12/2024
Last Update Date	:	03/26/2024

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