Provider Demographics
NPI:1427673367
Name:KEZIA E COLEMAN PSYD LLC
Entity type:Organization
Organization Name:KEZIA E COLEMAN PSYD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEZIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:314-472-3091
Mailing Address - Street 1:7711 BONHOMME AVE STE 720
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1908
Mailing Address - Country:US
Mailing Address - Phone:314-472-3091
Mailing Address - Fax:
Practice Address - Street 1:7777 BONHOMME AVE STE 1800
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1931
Practice Address - Country:US
Practice Address - Phone:314-472-3091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1346600061Medicaid
MO1790233153Medicaid
MO1992030027Medicaid