Provider Demographics
NPI:1952995565
Name:JELKS, ASHLEE
Entity Type:Individual
Prefix:
First Name:ASHLEE
Middle Name:
Last Name:JELKS
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 1:1404 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631
Mailing Address - Country:US
Mailing Address - Phone:601-890-6001
Mailing Address - Fax:
Practice Address - Street 1:1404 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MS
Practice Address - Zip Code:39631
Practice Address - Country:US
Practice Address - Phone:601-890-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-11829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist