Healthcare Provider Details

I. General information

NPI: 1770596918
Provider Name (Legal Business Name): JESSIE R TAYLOR M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 PALMETTO ROAD
VERONA MS
38879
US

IV. Provider business mailing address

PO BOX 429
VERONA MS
38879-0429
US

V. Phone/Fax

Practice location:
  • Phone: 662-566-5593
  • Fax: 662-566-4419
Mailing address:
  • Phone: 662-566-5593
  • Fax: 662-566-4419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number06260
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: