Provider Demographics
NPI:1366734667
Name:DANIELS, JESSIE CARL SR
Entity type:Individual
Prefix:MR
First Name:JESSIE
Middle Name:CARL
Last Name:DANIELS
Suffix:SR
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 1:207 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-6741
Mailing Address - Country:US
Mailing Address - Phone:229-378-8922
Mailing Address - Fax:
Practice Address - Street 1:207 SUNSET LN
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-6741
Practice Address - Country:US
Practice Address - Phone:229-378-8922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019429298172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver