Healthcare Provider Details

I. General information

NPI: 1174839880
Provider Name (Legal Business Name): JESSE LEE PALACIOS II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 MARVIN SHIELDS BLVD
GULFPORT MS
39501-9007
US

IV. Provider business mailing address

5501 MARVIN SHIELDS BLVD
GULFPORT MS
39501-9007
US

V. Phone/Fax

Practice location:
  • Phone: 228-871-2810
  • Fax: 228-871-2135
Mailing address:
  • Phone: 228-871-2810
  • Fax: 228-871-2135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: