Provider Demographics
NPI:1255940615
Name:JESUCAT, BERNUDE
Entity type:Individual
Prefix:
First Name:BERNUDE
Middle Name:
Last Name:JESUCAT
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 1:4141 PENWELL DR
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1283
Mailing Address - Country:US
Mailing Address - Phone:901-600-0966
Mailing Address - Fax:
Practice Address - Street 1:1024 US-61
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676
Practice Address - Country:US
Practice Address - Phone:662-363-3164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003197235Z00000X
MSS4746235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist