Healthcare Provider Details

I. General information

NPI: 1063605152
Provider Name (Legal Business Name): BRIAN ALLEN HENRY LPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 03/12/2023
Certification Date: 03/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NORTHTOWN DR SUITE 110
JACKSON MS
39211-3047
US

IV. Provider business mailing address

13 NORTHTOWN DR SUITE 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 TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA7693R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP017917A
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2693
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: