Healthcare Provider Details

I. General information

NPI: 1053667444
Provider Name (Legal Business Name): AMANDA B THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA CATHERINE BACON

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 OLD CANTON RD STE 130
JACKSON MS
39211-2946
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-7280
  • Fax: 601-977-6244
Mailing address:
  • Phone: 901-227-3255
  • Fax: 901-227-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2365
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: