Healthcare Provider Details

I. General information

NPI: 1144894916
Provider Name (Legal Business Name): JESSE CLEMENTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 SOUTHCREST CIR STE 108
SOUTHAVEN MS
38671-4775
US

IV. Provider business mailing address

597 DELTA EXPRESS LN APT 105
MEMPHIS TN
38103-1675
US

V. Phone/Fax

Practice location:
  • Phone: 901-484-8313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number217112
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901719
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: