Healthcare Provider Details

I. General information

NPI: 1407854938
Provider Name (Legal Business Name): KATHERINE MARIE JETT FAMILY NURSE PRACT.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST # LL10
JACKSON MS
39202-2000
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-2273
  • Fax: 601-714-3415
Mailing address:
  • Phone: 901-227-3255
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR869652
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: