Provider Demographics
NPI:1306449301
Name:BRISCOE, JAZZMEN (LMT #2540)
Entity type:Individual
Prefix:
First Name:JAZZMEN
Middle Name:
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:LMT #2540
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0082
Mailing Address - Country:US
Mailing Address - Phone:769-798-3089
Mailing Address - Fax:
Practice Address - Street 1:226 N BIERDEMAN RD
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4611
Practice Address - Country:US
Practice Address - Phone:601-526-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MS173C00000X, 246Y00000X, 374U00000X, 374U00000X
MS2540225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No173C00000XOther Service ProvidersReflexologist
No246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR-POMS2540OtherPOST OPERATIVE SURGICAL CARE PROVIDER
MSLMT2540OtherLICENSED MASSAGE THERAPIST