1407854938 NPI number — KATHERINE MARIE JETT FAMILY NURSE PRACT.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407854938 NPI number — KATHERINE MARIE JETT FAMILY NURSE PRACT.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JETT
Provider First Name:
KATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FAMILY NURSE PRACT.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407854938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 RIDGE LAKE BLVD STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-9446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-227-3255
Provider Business Mailing Address Fax Number:
901-227-8591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N STATE ST # LL10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39202-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-352-2273
Provider Business Practice Location Address Fax Number:
601-714-3415
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R869652 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01489305 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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