Provider Demographics
NPI:1306254255
Name:TULLOS, JESSICA MCCALLISTER (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MCCALLISTER
Last Name:TULLOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:MCCALLISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:103 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-9042
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:601-268-5819
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24078207P00000X, 207Q00000X, 207QS0010X
TXR6698207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0803724Medicaid
CA050586Medicare PIN