Provider Demographics
NPI:1700219276
Name:TAYLOR, JAMIE NICOLE (CCMA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 EDDIE AVE
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-5404
Mailing Address - Country:US
Mailing Address - Phone:228-233-8086
Mailing Address - Fax:
Practice Address - Street 1:5506 EDDIE AVE
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5404
Practice Address - Country:US
Practice Address - Phone:228-233-8086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3322-7849208D00000X
GACN0030021696376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No376K00000XNursing Service Related ProvidersNurse's Aide