Healthcare Provider Details

I. General information

NPI: 1780521005
Provider Name (Legal Business Name): MS. JERMELLODY CHRISTIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15120 POST MILL CT
DIBERVILLE MS
39540-5602
US

IV. Provider business mailing address

15120 POST MILL CT
DIBERVILLE MS
39540-5602
US

V. Phone/Fax

Practice location:
  • Phone: 662-822-6909
  • Fax:
Mailing address:
  • Phone: 662-822-6909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number202077
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: