Provider Demographics
NPI:1407428675
Name:JEFFERSON, KYLAYHA D
Entity type:Individual
Prefix:
First Name:KYLAYHA
Middle Name:D
Last Name:JEFFERSON
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 1:17940 FARMINGTON RD STE 302
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3159
Mailing Address - Country:US
Mailing Address - Phone:810-877-5919
Mailing Address - Fax:
Practice Address - Street 1:4036 BENNETT LAKE RD APT SUITE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-8709
Practice Address - Country:US
Practice Address - Phone:810-877-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI6362009617103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator