Basic Information
| Provider Information | |||||||||
| NPI: | 1730389990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17167 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394047167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012615995 | ||||||||
| FaxNumber: | 6012615335 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 HARDY ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012615995 | ||||||||
| FaxNumber: | 6012615335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 01/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 1021A | AL | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237600000X | A9340 | LA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237600000X | A3163 | MS | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 512I640023 | 01 | MS | PTAN | OTHER |