Provider Demographics
NPI:1427417070
Name:HAGAN, JESSICA NICOLE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:HOUGHTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2834 HONEY TREE DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7210
Mailing Address - Country:US
Mailing Address - Phone:510-566-3802
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-1030
Practice Address - Country:US
Practice Address - Phone:510-566-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC10747122300000X
TN11205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty