Basic Information
Provider Information | |||||||||
NPI: | 1780028829 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFRIES | ||||||||
FirstName: | KETURAH | ||||||||
MiddleName: | WILLIAMS | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BENNETT | ||||||||
OtherFirstName: | KETURAH | ||||||||
OtherMiddleName: | WILLIAMS | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4646 JOHN R ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482011916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3135761000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4646 JOHN R ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482011916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489903572 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2013 | ||||||||
LastUpdateDate: | 09/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | 4301103849 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
No ID Information.