Healthcare Provider Details

I. General information

NPI: 1770411803
Provider Name (Legal Business Name): ELAINA STANFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 TIMBER FALLS DR
JACKSON MS
39212-2347
US

IV. Provider business mailing address

2308 TIMBER FALLS DR
JACKSON MS
39212-2347
US

V. Phone/Fax

Practice location:
  • Phone: 601-596-5082
  • Fax:
Mailing address:
  • Phone: 601-596-5082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: