Provider Demographics
NPI:1326670977
Name:SMITH, TYESHA (ALL)
Entity Type:Individual
Prefix:
First Name:TYESHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ALL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 REBEL WOODS DR APT A8
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-3003
Mailing Address - Country:US
Mailing Address - Phone:601-317-4606
Mailing Address - Fax:
Practice Address - Street 1:200 REBEL WOODS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-3009
Practice Address - Country:US
Practice Address - Phone:601-317-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No251E00000XAgenciesHome Health