Provider Demographics
NPI:1629427497
Name:TATE, JESALYN AUTUMN (MD)
Entity Type:Individual
Prefix:
First Name:JESALYN
Middle Name:AUTUMN
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESALYN
Other - Middle Name:AUTUMN
Other - Last Name:MERRITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:956 COURT AVE
Mailing Address - Street 2:SUITE H314
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2814
Mailing Address - Country:US
Mailing Address - Phone:901-448-5814
Mailing Address - Fax:
Practice Address - Street 1:2000 OLATHE FL 4C
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-3438
Practice Address - Country:US
Practice Address - Phone:913-588-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-12
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-45028207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology