Healthcare Provider Details

I. General information

NPI: 1114495819
Provider Name (Legal Business Name): JESSECA HOLCOMB MS, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N PARKWAY
MEMPHIS TN
38112-1624
US

IV. Provider business mailing address

2000 N PARKWAY
MEMPHIS TN
38112-1624
US

V. Phone/Fax

Practice location:
  • Phone: 901-843-3276
  • Fax: 901-843-3749
Mailing address:
  • Phone: 901-843-3276
  • Fax: 901-843-3749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0000001389
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: