Provider Demographics
NPI:1336232529
Name:GARRETT, JESSE IVY III
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:IVY
Last Name:GARRETT
Suffix:III
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 1:114 CEDAR CREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-9765
Mailing Address - Country:US
Mailing Address - Phone:601-924-1500
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST WOODROW WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-9765
Practice Address - Country:US
Practice Address - Phone:601-364-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE6146OtherRPH LICENSE NUMBER