Provider Demographics
NPI:1669712311
Name:MACOON, YONETTE
Entity type:Individual
Prefix:
First Name:YONETTE
Middle Name:
Last Name:MACOON
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 1:1600 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4203
Mailing Address - Country:US
Mailing Address - Phone:601-371-1700
Mailing Address - Fax:
Practice Address - Street 1:1600 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4203
Practice Address - Country:US
Practice Address - Phone:601-371-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-17
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA 3829225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant