1720620123 NPI number — JESSICA BASKERVILLE PT, DPT, ATP

Table of content: JESSICA BASKERVILLE PT, DPT, ATP (NPI 1720620123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720620123 NPI number — JESSICA BASKERVILLE PT, DPT, ATP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASKERVILLE
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720620123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 SPRING LAKE CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655-9239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-202-4468
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 BURKE CALHOUN CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALHOUN CITY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38916-9690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-234-8559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT4802 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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