Healthcare Provider Details

I. General information

NPI: 1902454390
Provider Name (Legal Business Name): JERRY ANN RUTLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1196 SIMPSON HIGHWAY 469
HARRISVILLE MS
39082-4219
US

IV. Provider business mailing address

1196 SIMPSON HWY 469
HARRISVILLE MS
39082
US

V. Phone/Fax

Practice location:
  • Phone: 601-842-7243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: