Healthcare Provider Details

I. General information

NPI: 1215512256
Provider Name (Legal Business Name): TINA A JEFCOAT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 WEST DR
LAUREL MS
39440-4702
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-426-7520
  • Fax: 601-428-5790
Mailing address:
  • Phone: 601-705-1901
  • Fax: 601-705-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR858299
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: