Provider Demographics
NPI:1720551740
Name:JENNINGS, MAKETTA
Entity Type:Individual
Prefix:
First Name:MAKETTA
Middle Name:
Last Name:JENNINGS
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 1:2160 S FRONTAGE RD APT 17D
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5181
Mailing Address - Country:US
Mailing Address - Phone:601-618-8632
Mailing Address - Fax:
Practice Address - Street 1:8677 HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-7047
Practice Address - Country:US
Practice Address - Phone:601-618-8632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS253Z00000X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No253Z00000XAgenciesIn Home Supportive Care