Provider Demographics
NPI:1225691769
Name:DYER, JALISA MARIE (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:JALISA
Middle Name:MARIE
Last Name:DYER
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:ROXIE
Mailing Address - State:MS
Mailing Address - Zip Code:39661-5003
Mailing Address - Country:US
Mailing Address - Phone:601-620-8303
Mailing Address - Fax:
Practice Address - Street 1:3825 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-5725
Practice Address - Country:US
Practice Address - Phone:225-387-1167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903301363L00000X, 363LW0102X
LA214139363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner