1699897280 NPI number — DR. JENNIFER STEWART MIZE AU.D., CCC-A

Table of content: DR. JENNIFER STEWART MIZE AU.D., CCC-A (NPI 1699897280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699897280 NPI number — DR. JENNIFER STEWART MIZE AU.D., CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIZE
Provider First Name:
JENNIFER
Provider Middle Name:
STEWART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU.D., CCC-A
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:
1699897280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38803-2180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-844-3583
Provider Business Mailing Address Fax Number:
662-840-8354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 PEGRAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801-6322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-844-3583
Provider Business Practice Location Address Fax Number:
662-840-8354
Provider Enumeration Date:
04/04/2007

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: 237600000X , with the licence number:  A2377 , 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)

  • Identifier: 00770450 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com