Provider Demographics
NPI:1962170829
Name:HAILEY, JASMINE DANIELLE
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:DANIELLE
Last Name:HAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JASMINE
Other - Middle Name:DANIELLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1655 RANDOLPH PL APT 8
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-8318
Mailing Address - Country:US
Mailing Address - Phone:901-679-4657
Mailing Address - Fax:
Practice Address - Street 1:50 GOODMAN RD W STE 2
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9403
Practice Address - Country:US
Practice Address - Phone:662-470-2284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4242-21122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist