Healthcare Provider Details

I. General information

NPI: 1467981308
Provider Name (Legal Business Name): JESSICA BROOKE GUNN LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 I 55 N
JACKSON MS
39206-3616
US

IV. Provider business mailing address

5411 I 55 N
JACKSON MS
39206-3616
US

V. Phone/Fax

Practice location:
  • Phone: 601-942-2968
  • Fax: 601-510-9012
Mailing address:
  • Phone: 601-942-2968
  • Fax: 601-510-9012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: