Healthcare Provider Details

I. General information

NPI: 1811467731
Provider Name (Legal Business Name): JESSICA JAMES DEFORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6858 SWINNEA RD BLDG 6B
SOUTHAVEN MS
38671-9493
US

IV. Provider business mailing address

1493 BAKER RD
LAKE CORMORANT MS
38641-9727
US

V. Phone/Fax

Practice location:
  • Phone: 662-426-6136
  • Fax:
Mailing address:
  • Phone: 662-292-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: