Healthcare Provider Details

I. General information

NPI: 1215596952
Provider Name (Legal Business Name): MS. KRISTAIN JERAE COKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

929 DR. D.B. TODD JR. BLVD
NASHVILLE TN
37208
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-6028
  • Fax:
Mailing address:
  • Phone: 404-935-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0006806
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: