Basic Information
| Provider Information | |||||||||
| NPI: | 1417525007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOULDS | ||||||||
| FirstName: | JARROD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1736 COUNTRY CLUB DR | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393053405 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1314 19TH AVE | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014830011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2021 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 901709 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.