Healthcare Provider Details

I. General information

NPI: 1114555000
Provider Name (Legal Business Name): GARRETT MCTYRE MINOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

120 DISTRICT BLVD APT 416
JACKSON MS
39211-6388
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone: 731-693-0932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberT6168
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: