Healthcare Provider Details

I. General information

NPI: 1922814284
Provider Name (Legal Business Name): JOHN DEAN PUCKETT PLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LAKELAND DR STE 203
FLOWOOD MS
39232-8853
US

IV. Provider business mailing address

5525 PINE LANE DR
JACKSON MS
39211-4019
US

V. Phone/Fax

Practice location:
  • Phone: 601-228-6907
  • Fax:
Mailing address:
  • Phone: 601-573-2858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-0725
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: