Healthcare Provider Details

I. General information

NPI: 1851289920
Provider Name (Legal Business Name): KAYLIE JERROLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 HIGHWAY 64 STE 100
EADS TN
38028-3322
US

IV. Provider business mailing address

1456 ROSEMARY LN
MEMPHIS TN
38104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 901-465-2382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12882
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: