Provider Demographics
NPI:1952068330
Name:HAMPTON, JENISHA NIKITA (OWNER)
Entity Type:Individual
Prefix:MRS
First Name:JENISHA
Middle Name:NIKITA
Last Name:HAMPTON
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 LACLEDE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-6025
Mailing Address - Country:US
Mailing Address - Phone:901-679-1271
Mailing Address - Fax:
Practice Address - Street 1:401 LACLEDE AVE APT 1
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38126-6025
Practice Address - Country:US
Practice Address - Phone:901-679-1271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS802119171343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS802119171Medicaid