Provider Demographics
NPI:1467479485
Name:STENNETT, JERRY L (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:STENNETT
Suffix:
Gender:M
Credentials:MD
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 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 BAPTIST BLVD
Practice Address - Street 2:STE 407
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2011
Practice Address - Country:US
Practice Address - Phone:662-241-4223
Practice Address - Fax:662-241-4460
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010424Medicaid
MS508326YK4LMedicare PIN
B66191Medicare UPIN