Healthcare Provider Details

I. General information

NPI: 1255924346
Provider Name (Legal Business Name): PMGROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2021
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FAIRWAY DR
HATTIESBURG MS
39401-7715
US

IV. Provider business mailing address

300 FAIRWAY DR
HATTIESBURG MS
39401-7715
US

V. Phone/Fax

Practice location:
  • Phone: 601-329-1321
  • Fax:
Mailing address:
  • Phone: 601-329-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB CORNELIUS PARKER
Title or Position: PSYCHIATRIST
Credential: DO,MD
Phone: 601-329-1321