Healthcare Provider Details

I. General information

NPI: 1134992431
Provider Name (Legal Business Name): COURTNEY ELIZABETH NEWSOME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 315
JACKSON MS
39216-4607
US

IV. Provider business mailing address

4235 CANTERBURY CT
JACKSON MS
39211-6205
US

V. Phone/Fax

Practice location:
  • Phone: 601-414-9530
  • Fax:
Mailing address:
  • Phone: 601-985-8272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00789
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: