Provider Demographics
NPI:1679249627
Name:MOLDER, JERMICKA (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:JERMICKA
Middle Name:
Last Name:MOLDER
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:JERMICKA
Other - Middle Name:
Other - Last Name:MOLDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOUBLE DIAMOND HAIR
Mailing Address - Street 1:8923 SAILING DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-2796
Mailing Address - Country:US
Mailing Address - Phone:409-455-4391
Mailing Address - Fax:
Practice Address - Street 1:4570 FM 1960 RD E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-2418
Practice Address - Country:US
Practice Address - Phone:409-455-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1608544335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier