Provider Demographics
NPI:1861717464
Name:JEFFERSON, KENDALL DENISE (MD)
Entity type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:DENISE
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KENDALL
Other - Middle Name:DENISE
Other - Last Name:AGOCHUKWU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:750 TOWNPARK LN NW STE 113
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5824
Mailing Address - Country:US
Mailing Address - Phone:404-365-0966
Mailing Address - Fax:
Practice Address - Street 1:750 TOWNPARK LN NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5824
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01164208000000X
GA77694208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA77694OtherLICENSE