Provider Demographics
NPI:1114755659
Name:BARBOUR, KATLYN
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:BARBOUR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 PINE RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5708
Mailing Address - Country:US
Mailing Address - Phone:601-213-7600
Mailing Address - Fax:
Practice Address - Street 1:1627 PINE RIDGE PL
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5708
Practice Address - Country:US
Practice Address - Phone:601-213-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA18761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program