Provider Demographics
NPI:1902109903
Name:CARTER, JEFFREY WAYNE
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WAYNE
Last Name:CARTER
Suffix:
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:P.O.BOX 8774
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701
Mailing Address - Country:US
Mailing Address - Phone:662-251-1064
Mailing Address - Fax:
Practice Address - Street 1:1809 7TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701
Practice Address - Country:US
Practice Address - Phone:662-251-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS972770171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS972770OtherBUSINESS ID
MS972770OtherBUSINESS ID