Provider Demographics
NPI:1730970070
Name:HAYNES, MARKETTA
Entity type:Individual
Prefix:
First Name:MARKETTA
Middle Name:
Last Name:HAYNES
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 1:128 BEDFORD WHITE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5930
Mailing Address - Country:US
Mailing Address - Phone:731-217-7884
Mailing Address - Fax:
Practice Address - Street 1:128 BEDFORD WHITE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-5930
Practice Address - Country:US
Practice Address - Phone:731-217-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251S00000X, 320600000X, 320900000X, 3747P1801X
TN00221558376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant