Basic Information
| Provider Information | |||||||||
| NPI: | 1144855842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISTER | ||||||||
| FirstName: | JENNINGS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 CAMDEN LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391107030 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019841000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2020 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.