Healthcare Provider Details

I. General information

NPI: 1053786996
Provider Name (Legal Business Name): BAPTIST PT- LYMPHEDEMA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

1225 N STATE ST
JACKSON MS
39202-2064
US

V. Phone/Fax

Practice location:
  • Phone: 601-974-6243
  • Fax:
Mailing address:
  • Phone: 601-974-6243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AMY GRISSETT
Title or Position: BILLING MANAGER
Credential:
Phone: 601-944-1717