Provider Demographics
NPI:1477665065
Name:COLEMAN, JASON KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:KENNETH
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4036 ROBERTSON GIN RD
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8228
Mailing Address - Country:US
Mailing Address - Phone:662-429-3419
Mailing Address - Fax:
Practice Address - Street 1:3964 GOODMAN RD E
Practice Address - Street 2:SUITE 128
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8761
Practice Address - Country:US
Practice Address - Phone:662-893-7337
Practice Address - Fax:662-893-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3112-991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660436Medicaid