Basic Information
| Provider Information | |||||||||
| NPI: | 1407854938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JETT | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | FAMILY NURSE PRACT. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST # LL10 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013522273 | ||||||||
| FaxNumber: | 6017143415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R869652 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 01489305 | 05 | MS | MEDICAID |