Healthcare Provider Details

I. General information

NPI: 1306180963
Provider Name (Legal Business Name): MARILYN MAIZLAND KERR L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6026 FERNCREEK DR
JACKSON MS
39211-2725
US

IV. Provider business mailing address

6026 FERNCREEK DR
JACKSON MS
39211-2725
US

V. Phone/Fax

Practice location:
  • Phone: 601-454-9117
  • Fax:
Mailing address:
  • Phone: 601-454-9117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number917
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: