Healthcare Provider Details

I. General information

NPI: 1588757884
Provider Name (Legal Business Name): JO ANN CALCOTE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST WOODROW WILSON AVENUE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

6231 NORTHLAKE CIRCLE
JACKSON MS
39211
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax:
Mailing address:
  • Phone: 601-957-0096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number560226
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: