Provider Demographics
NPI:1467126060
Name:LUCKETT, CASSANDRA E
Entity Type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:E
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 CONCORD DR NE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4237
Mailing Address - Country:US
Mailing Address - Phone:205-373-9710
Mailing Address - Fax:
Practice Address - Street 1:5525 CONCORD DR NE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4237
Practice Address - Country:US
Practice Address - Phone:205-373-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171000000X, 374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty