Provider Demographics
NPI:1316287675
Name:STEPHENS, JERUSHA DEGROOTE (LAC)
Entity type:Individual
Prefix:MRS
First Name:JERUSHA
Middle Name:DEGROOTE
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4500 I 55 N
Mailing Address - Street 2:SUITE 128
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5930
Mailing Address - Country:US
Mailing Address - Phone:601-366-7721
Mailing Address - Fax:601-366-7649
Practice Address - Street 1:4500 I 55 N
Practice Address - Street 2:SUITE 128
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5930
Practice Address - Country:US
Practice Address - Phone:601-366-7721
Practice Address - Fax:601-366-7649
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAC00001171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist