DR. KEITH A MICETICH (NPI# 1427026137) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1427026137 |
| Entity Type | Individual |
| Full Name | DR. KEITH A MICETICH |
| Credential | MD |
| Practice Address |
72 Physicians Dr Jackson TN 38305-2070 |
| Practice Telephone | 7316684455 |
| Practice Fax Number | 7316689007 |
| Mailing Telephone | 7316684455 |
| Mailing Fax Number | 7316644508 |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2011-11-02 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 174400000X | Specialist | 26274 | TN | Other Service Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| TN | BLUE CROSS BLUE SHIELD | 3009628 | 01 |
| Street Address |
72 PHYSICIANS DR |
| City | JACKSON |
| State | TN |
| Zip Code | 38305-2070 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1265966634 | Tayler M Johnston | Nurse Practitioner | 72 Physicians Dr, Jackson, TN 38305 | 2017-04-12 |
| 1114346673 | Rachel Holmes | Nurse Practitioner | 72 Physicians Dr, Jackson, TN 38305-2070 | 2014-04-14 |
| 1235155276 | Jackson Regional Womens Center | Obstetrics & Gynecology | 72 Physicians Dr, Jackson, TN 38305-2070 | 2006-07-14 |
| 1376511097 | Sandra J Boxell | Specialist | 72 Physicians Dr, Jackson, TN 38305-2070 | 2006-03-09 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1427656818 | Kimaya Jelks | Specialist | 1869 45 Hwy Bypass, Suite 2b, Jackson, TN 38305 | 2020-10-16 |
| 1821600578 | Maame Obeng | Pharmacist | 3144 North Highland Avenue, Jackson, TN 38305 | 2020-08-22 |
| 1700361904 | James Cowie | Psychologist | 156c West University Pkwy, Jackson, TN 38305 | 2018-10-03 |
| 1700372109 | Chad Zawacki | Physician Assistant | 147 North Star Drive, Jackson, TN 38305 | 2018-07-09 |
| 1104323070 | Golden Years Adult Day Care | Clinic/Center | 155 Carriage Dr Suite A, Jackson, TN 38305 | 2018-04-09 |
| 1245754563 | Tanika Annette Gillard | Massage Therapist | 4 Hampton Ln, Jackson, TN 38305 | 2017-07-28 |
| 1316488117 | Lakisha T Ingram | Counselor | 168 Greencastle Dr, Jackson, TN 38305 | 2017-03-13 |
| 1619421567 | D & L Wellness Inc | Community/Behavioral Health | 154 Carriage House Dr., Jackson, TN 38305 | 2016-08-09 |
| 1649637638 | Advance Choice Home Care LLC | In Home Supportive Care | 1028 Ashport Rd., Jackson, TN 38305 | 2016-01-21 |
| 1942666151 | Neurohealth Solutions Inc. | Clinic/Center | 174 Murray Guard Dr. Suite E, Jackson, TN 38305 | 2016-01-05 |
| Find all providers in zip 38305 | ||||
| Taxonomy Code | 174400000X |
| Grouping | Other Service Providers |
| Classification | Specialist |
| An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |
| Notes: Source: Expanded from Webster’s II New Riverside University Dictionary, Boston: Riverside Publishing Company, 1974. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1427656818 | Kimaya Jelks | Specialist | 1869 45 Hwy Bypass, Suite 2b, Jackson, TN 38305 | 2020-10-16 |
| 1396271565 | Karlisha Britton | Specialist | 7 Lakeland Circle, Suite 300, Jackson, MS 39216 | 2017-05-10 |
| 1922545896 | Paul Edward Ruttle | Specialist | 2640 Trader Rd, Jackson, WY 83001-8321 | 2017-01-30 |
| 1780121483 | Andrew Callis | Specialist | 5303 Old Cape Rd E, Jackson, MO 63755-3850 | 2017-01-19 |
| 1538617055 | Jonathan Parker | Specialist | 95 Riverport Dr, Jackson, TN 38301-5748 | 2016-09-13 |
| 1386096600 | Miriam Bick | Specialist | 4 Florida Pl, Jackson, NJ 08527-1816 | 2016-07-11 |
| 1326429572 | Alonzo Roberts | Specialist | 6110 Highway 18 W, Jackson, MS 39209-9322 | 2015-06-13 |
| 1407289275 | Andrew Francis Charland | Specialist | N168w22224 Main St Ste E, Jackson, WI 53037-9321 | 2013-08-15 |
| 1265872501 | Robyn Abbott Roberts | Specialist | 1904 Lakeland Dr, Suite D, Jackson, MS 39216-5038 | 2013-07-01 |
| 1053754580 | Massage Revolution | Specialist | 210 E Capitol St, Ste M-142, Jackson, MS 39201-2306 | 2013-04-15 |
| Find all providers in JACKSON | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.