Healthcare Provider Details

I. General information

NPI: 1851530752
Provider Name (Legal Business Name): JEANNETTE SMITH CLEMENTS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 NOTTINGHAM DR
OXFORD MS
38655-4414
US

IV. Provider business mailing address

740 NOTTINGHAM DR
OXFORD MS
38655-4414
US

V. Phone/Fax

Practice location:
  • Phone: 662-816-6349
  • Fax:
Mailing address:
  • Phone: 662-816-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1035
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: