Healthcare Provider Details

I. General information

NPI: 1073444162
Provider Name (Legal Business Name): JEQUAILIA N BURNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 COLLEGE ST
COLUMBUS MS
39701-5821
US

IV. Provider business mailing address

350 WHITE STATION RD
WEST POINT MS
39773-0457
US

V. Phone/Fax

Practice location:
  • Phone: 662-241-6217
  • Fax:
Mailing address:
  • Phone: 662-295-9657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0954
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: