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General NPI Number Information
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NPI Number | 1912933672
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Entity Type | Individual
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Provider Name | LARA J TEAL CLEMENT MD
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Gender | Female
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Dates
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Enumeration Date | 06/24/2006
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Last Update Date | 05/25/2021
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Provider Practice Location Address
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Address Line | MAGNOLIA SENIOR CARE 3701 PETER QUINN DR
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City | JACKSON
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State | MS
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Zip | 39213
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Country | US
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Telephone | 601-206-0901
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Fax | 888-240-6288
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Provider Business Mailing Address
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Address Line | 200 AMITY LN
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City | BRANDON
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State | MS
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Zip | 39047-7941
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Country | US
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Telephone | 601-206-0901
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Fax | 888-240-6288
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 16858
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License Number State | MS
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