Provider Demographics
NPI:1811254055
Name:JEFFERSON, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:500 LANIER AVE W STE 701
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7643
Mailing Address - Country:US
Mailing Address - Phone:770-460-9122
Mailing Address - Fax:
Practice Address - Street 1:500 LANIER AVE W STE 701
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7643
Practice Address - Country:US
Practice Address - Phone:770-460-9122
Practice Address - Fax:770-460-9132
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACERTIFICATION174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist