Healthcare Provider Details

I. General information

NPI: 1851856025
Provider Name (Legal Business Name): MRS. JACQUELINE HUDSON MYLES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 HEDGEROW DR
MEMPHIS TN
38109-4424
US

IV. Provider business mailing address

3940 HEDGEROW DR
MEMPHIS TN
38109-4424
US

V. Phone/Fax

Practice location:
  • Phone: 901-679-1687
  • Fax:
Mailing address:
  • Phone: 901-679-1687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: