Provider Demographics
NPI:1104847094
Name:DEBERRY, KENDRA ALEXIS (PTA)
Entity Type:Individual
Prefix:MR
First Name:KENDRA
Middle Name:ALEXIS
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:KENDRA
Other - Middle Name:ALEXIS
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5600 GOODMAN RD STE D
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:662-895-5454
Mailing Address - Fax:662-895-4546
Practice Address - Street 1:5600 GOODMAN RD STE D
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:662-895-5454
Practice Address - Fax:662-895-4546
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA2517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant