Provider Demographics
NPI:1801692462
Name:JEFFERSON, WENDALL KEITH
Entity type:Individual
Prefix:
First Name:WENDALL
Middle Name:KEITH
Last Name:JEFFERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-6044
Mailing Address - Country:US
Mailing Address - Phone:404-307-5251
Mailing Address - Fax:
Practice Address - Street 1:1719 12TH ST
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-6044
Practice Address - Country:US
Practice Address - Phone:404-307-5251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor