Provider Demographics
NPI:1407637598
Name:KING, JEFFREY ADAM
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ADAM
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 RICHARD PL NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-1924
Mailing Address - Country:US
Mailing Address - Phone:330-265-4503
Mailing Address - Fax:
Practice Address - Street 1:1136 RICHARD PL NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-1924
Practice Address - Country:US
Practice Address - Phone:330-265-4503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant