Healthcare Provider Details

I. General information

NPI: 1841056751
Provider Name (Legal Business Name): TEQUILA JONES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 TREASURE LN
STARKVILLE MS
39759-8770
US

IV. Provider business mailing address

581 TREASURE LN
STARKVILLE MS
39759-8770
US

V. Phone/Fax

Practice location:
  • Phone: 662-640-4595
  • Fax:
Mailing address:
  • Phone: 662-694-2437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number889432
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number889432
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: