Healthcare Provider Details

I. General information

NPI: 1649252057
Provider Name (Legal Business Name): JACKIE E. MCHENRY II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2005
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BURKE CALHOUN CITY RD
CALHOUN CITY MS
38916
US

IV. Provider business mailing address

1111 N CAUSEWAY BLVD
MANDEVILLE LA
70471-3409
US

V. Phone/Fax

Practice location:
  • Phone: 662-628-6300
  • Fax:
Mailing address:
  • Phone: 985-773-1844
  • Fax: 985-893-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14485
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: