Provider Demographics
NPI:1760698047
Name:JERNIGAN, STEPHEN ROSS (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ROSS
Last Name:JERNIGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 S COLORADO ST STE A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7275
Mailing Address - Country:US
Mailing Address - Phone:662-335-8332
Mailing Address - Fax:662-335-8852
Practice Address - Street 1:1707 S COLORADO ST STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7275
Practice Address - Country:US
Practice Address - Phone:662-335-8332
Practice Address - Fax:662-335-8852
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9015486Medicaid
MS9015486Medicaid
MSPT1045Medicare UPIN