Healthcare Provider Details

I. General information

NPI: 1750103974
Provider Name (Legal Business Name): AMANDA PARKER CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

114 WILLOW PL
BRANDON MS
39047-6389
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax:
Mailing address:
  • Phone: 601-502-6054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License NumberRCP-2132
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: