1316287675 NPI number — MRS. JERUSHA DEGROOTE STEPHENS LAC

Table of content: MRS. JERUSHA DEGROOTE STEPHENS LAC (NPI 1316287675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316287675 NPI number — MRS. JERUSHA DEGROOTE STEPHENS LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEPHENS
Provider First Name:
JERUSHA
Provider Middle Name:
DEGROOTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LAC
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:
1316287675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 I 55 N
Provider Second Line Business Mailing Address:
SUITE 128
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39211-5930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-366-7721
Provider Business Mailing Address Fax Number:
601-366-7649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 I 55 N
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39211-5930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-366-7721
Provider Business Practice Location Address Fax Number:
601-366-7649
Provider Enumeration Date:
02/25/2013

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: 171100000X , with the licence number:  AC00001 , 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)





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