Healthcare Provider Details

I. General information

NPI: 1386539617
Provider Name (Legal Business Name): AMANDA M MCGOWIN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NORTHTOWN DR STE 110
JACKSON MS
39211-3047
US

IV. Provider business mailing address

13 NORTHTOWN DR STE 110
JACKSON MS
39211-3047
US

V. Phone/Fax

Practice location:
  • Phone: 601-206-9195
  • Fax: 601-957-8391
Mailing address:
  • Phone: 601-206-9195
  • Fax: 601-957-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT4934
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: