Healthcare Provider Details

I. General information

NPI: 1659213338
Provider Name (Legal Business Name): JENNA EVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2154 GOODMAN RD W
HORN LAKE MS
38637-1303
US

IV. Provider business mailing address

115 ISLE CREEK DR
MEMPHIS TN
38103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 662-393-9200
  • Fax:
Mailing address:
  • Phone: 479-685-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112761
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: