Basic Information
| Provider Information | |||||||||
| NPI: | 1366028292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Credential: | LPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 563 CLUBHOUSE DR | ||||||||
| Address2: | |||||||||
| City: | PEARL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392089506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623723000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13 NORTHTOWN DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392113047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 6921 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 6921 | 01 | MS | PRIVATE INSURANCE | OTHER |