Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT4882 | MS |
NPI | 1003202953 |
---|---|
Provider Name | Mrs. Jessica Brooke Pettit |
First Address | West Point, MS 39773-2760 |
Second Address | West Point, MS 39773-2760 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2015 |
Last Update Date | 14/05/2020 |