Provider Demographics
NPI:1649356478
Name:DEHART, GINNY REBECCA (PT)
Entity type:Individual
Prefix:MISS
First Name:GINNY
Middle Name:REBECCA
Last Name:DEHART
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5545 PINE LANE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4019
Mailing Address - Country:US
Mailing Address - Phone:601-957-2976
Mailing Address - Fax:
Practice Address - Street 1:5545 PINE LANE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4019
Practice Address - Country:US
Practice Address - Phone:601-957-2976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03083791Medicaid