Healthcare Provider Details

I. General information

NPI: 1992368799
Provider Name (Legal Business Name): KACEY HAVARD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACEY JONES

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N BROAD ST
FOREST MS
39074-3508
US

IV. Provider business mailing address

330 N BROAD ST
FOREST MS
39074-3508
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax:
Mailing address:
  • Phone: 601-498-5010
  • Fax: 601-469-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number891900
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number903354
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: