Provider Demographics
NPI:1063025062
Name:TERRY, FREDERICK MARVIN
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MARVIN
Last Name:TERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-0465
Mailing Address - Country:US
Mailing Address - Phone:601-942-7689
Mailing Address - Fax:
Practice Address - Street 1:2135 HENRY HILL DR STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2013
Practice Address - Country:US
Practice Address - Phone:601-942-7689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X, 385H00000X
MS890892163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care