Provider Demographics
NPI:1093095523
Name:LAUDERDALE, JESSICA ANNE (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:LAUDERDALE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-2807
Mailing Address - Country:US
Mailing Address - Phone:662-489-6041
Mailing Address - Fax:
Practice Address - Street 1:11 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2807
Practice Address - Country:US
Practice Address - Phone:662-489-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2069591208D00000X
MS23832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice