=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609699727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA HEARING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3964 GOODMAN RD E STE 130
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-8762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-412-2053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3964 GOODMAN RD E STE 130
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672-8762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-205-0615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF AUDIOLOGY/OWNER
-----------------------------------------------------
Name | DR. JENNIFER LEIGH CRIDER
-----------------------------------------------------
Credential | AUD
-----------------------------------------------------
Telephone | 662-205-0615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------