Provider Demographics
NPI:1336886936
Name:PRINCE, JEVORIUS K
Entity Type:Individual
Prefix:
First Name:JEVORIUS
Middle Name:K
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SCHOOL HOUSE LN
Mailing Address - Street 2:
Mailing Address - City:DE KALB
Mailing Address - State:MS
Mailing Address - Zip Code:39328-9469
Mailing Address - Country:US
Mailing Address - Phone:601-479-3399
Mailing Address - Fax:
Practice Address - Street 1:150 SCHOOL HOUSE LN
Practice Address - Street 2:
Practice Address - City:DE KALB
Practice Address - State:MS
Practice Address - Zip Code:39328-9469
Practice Address - Country:US
Practice Address - Phone:601-479-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3119225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty