1205574795 NPI number — MS. JALESA DENISE NICKSON ED.S

Table of content: LESLEY LOVALA KAHNUMBOH (NPI 1275410326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205574795 NPI number — MS. JALESA DENISE NICKSON ED.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICKSON
Provider First Name:
JALESA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ED.S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205574795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 SCR 581B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39153-5438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-577-2599
Provider Business Mailing Address Fax Number:
601-952-4398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 SCR 581B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39153-5438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-577-2599
Provider Business Practice Location Address Fax Number:
601-952-4398
Provider Enumeration Date:
05/24/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  216761 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YS0200X , with the licence number: 216761 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)