Healthcare Provider Details

I. General information

NPI: 1245022292
Provider Name (Legal Business Name): LAKENDRA JALEESA MONTGOMERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2025
Last Update Date: 05/17/2025
Certification Date: 05/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 6TH ST N APT 47
COLUMBUS MS
39701-3455
US

IV. Provider business mailing address

1125 6TH ST N APT 47
COLUMBUS MS
39701-3455
US

V. Phone/Fax

Practice location:
  • Phone: 662-352-9394
  • Fax:
Mailing address:
  • Phone: 662-352-9394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: