Healthcare Provider Details

I. General information

NPI: 1104214931
Provider Name (Legal Business Name): JUSTIN HEWITT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2015
Last Update Date: 01/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PEACHTREE ST
JACKSON MS
39202-1754
US

IV. Provider business mailing address

1500 PEACHTREE ST
JACKSON MS
39202-1754
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-8791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0670
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: