Individual
DR. KENTRELL MARIE LIDDELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2104 THOUSAND OAKS DR, JACKSON, MS 39212-2048
(601) 346-7450
(601) 346-7451
Mailing address
2104 THOUSAND OAKS DR, JACKSON, MS 39212-2048
(601) 346-7450
(601) 346-7451
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
17997
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
08072071
—
MS
01
—
11859914
UNITED HEALTHCARE
MS
Enumeration date
08/15/2006
Last updated
04/09/2013
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