Healthcare Provider Details

I. General information

NPI: 1972261048
Provider Name (Legal Business Name): SHERRICE BENFORD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5888 RIDGEWOOD RD STE B
JACKSON MS
39211-2644
US

IV. Provider business mailing address

5888 RIDGEWOOD RD STE B
JACKSON MS
39211-2644
US

V. Phone/Fax

Practice location:
  • Phone: 601-978-1798
  • Fax: 601-978-1799
Mailing address:
  • Phone: 601-978-1798
  • Fax: 601-978-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA2830
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: