Healthcare Provider Details

I. General information

NPI: 1902550817
Provider Name (Legal Business Name): JENNIFER DENTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 GALAXIE DR
JACKSON MS
39206-4335
US

IV. Provider business mailing address

5140 GALAXIE DR
JACKSON MS
39206-4335
US

V. Phone/Fax

Practice location:
  • Phone: 662-714-3122
  • Fax: 888-228-1594
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA6919
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: