Provider Demographics
NPI:1316563232
Name:JEZIERSKI, KIMBERY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERY
Middle Name:ANN
Last Name:JEZIERSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 SUMMIT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3364
Mailing Address - Country:US
Mailing Address - Phone:248-409-1105
Mailing Address - Fax:248-745-6872
Practice Address - Street 1:279 SUMMIT DR STE 200
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3364
Practice Address - Country:US
Practice Address - Phone:248-409-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225936163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health