Provider Demographics
NPI:1356808422
Name:MCDANIEL, KATIE JENKINS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:JENKINS
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:705 SISK AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3413
Mailing Address - Country:US
Mailing Address - Phone:662-371-1326
Mailing Address - Fax:662-371-1325
Practice Address - Street 1:1626 HIGHWAY 30 E
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-371-1326
Practice Address - Fax:662-371-1325
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA-00412363A00000X
MSPA00412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant