Provider Demographics
NPI:1922578996
Name:ADKISSON, JERRILYN DIANE
Entity Type:Individual
Prefix:MRS
First Name:JERRILYN
Middle Name:DIANE
Last Name:ADKISSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N INGRAM RD
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5233
Mailing Address - Country:US
Mailing Address - Phone:573-471-3770
Mailing Address - Fax:
Practice Address - Street 1:208 N INGRAM RD
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5233
Practice Address - Country:US
Practice Address - Phone:573-471-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063620565OtherNPI
MOLC001488560OtherMISSOURI SECRETARY OF STATE