Basic Information
Provider Information | |||||||||
NPI: | 1811297120 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNETT | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 415 S 28TH AVE | ||||||||
Address2: |   | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 394017246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012611550 | ||||||||
FaxNumber: | 6015795240 | ||||||||
Practice Location | |||||||||
Address1: | 7127 HIGHWAY 98 WEST | ||||||||
Address2: | SUITE 40 | ||||||||
City: | HATTIESBURG | ||||||||
State: | MS | ||||||||
PostalCode: | 39402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6012611550 | ||||||||
FaxNumber: | 6012682530 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2010 | ||||||||
LastUpdateDate: | 08/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4051 | MS | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | P01206663 | 01 | MS | RAILROAD MEDICARE | OTHER | 0463784 | 01 | MS | CIGNA | OTHER | 9007864 | 01 | MS | AETNA | OTHER | 00237896 | 05 | MS |   | MEDICAID | 3451245 | 01 | MS | UNITED HEALTHCARE | OTHER |