Provider Demographics
NPI:1467711408
Name:LAVENDER, JESSICA SHARLEEN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHARLEEN
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-7512
Mailing Address - Country:US
Mailing Address - Phone:601-624-2685
Mailing Address - Fax:
Practice Address - Street 1:1100 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051
Practice Address - Country:US
Practice Address - Phone:601-267-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23866207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS514887YJ5DMedicare PIN