Healthcare Provider Details

I. General information

NPI: 1508860214
Provider Name (Legal Business Name): JASON GREGORY BEASLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S HOLLY AVE
COLLINS MS
39428-3801
US

IV. Provider business mailing address

606 GERALD MCRANEY ST
COLLINS MS
39428-3801
US

V. Phone/Fax

Practice location:
  • Phone: 601-765-9393
  • Fax: 601-765-9363
Mailing address:
  • Phone: 601-765-9393
  • Fax: 601-765-9363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18440
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: