Provider Demographics
NPI:1407409428
Name:MERMIS, JENISHA RAE
Entity Type:Individual
Prefix:
First Name:JENISHA
Middle Name:RAE
Last Name:MERMIS
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 1:327 W SUNSET RD APT 2228
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:520-308-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians