Provider Demographics
NPI:1639657604
Name:CLEMENTS, JODI B (PA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:B
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:670 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3014
Mailing Address - Country:US
Mailing Address - Phone:662-328-1012
Mailing Address - Fax:662-328-1507
Practice Address - Street 1:670 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3014
Practice Address - Country:US
Practice Address - Phone:662-328-1012
Practice Address - Fax:662-328-1507
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05172735Medicaid