Provider Demographics
NPI:1811467731
Name:DEFORE, JESSICA JAMES
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JAMES
Last Name:DEFORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CORMORANT
Mailing Address - State:MS
Mailing Address - Zip Code:38641-9727
Mailing Address - Country:US
Mailing Address - Phone:662-292-2252
Mailing Address - Fax:
Practice Address - Street 1:6858 SWINNEA RD BLDG 6B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9493
Practice Address - Country:US
Practice Address - Phone:662-426-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician