Healthcare Provider Details

I. General information

NPI: 1790567378
Provider Name (Legal Business Name): ANTONIO LAKENDRICK CORTEZ MCBETH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

577 STORM STORM RD.
LENA MS
39094
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number910807
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number907859
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: