Healthcare Provider Details

I. General information

NPI: 1972447621
Provider Name (Legal Business Name): DERRICK DEWAYNER DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 LAKELAND DR # 900
JACKSON MS
39216-5028
US

IV. Provider business mailing address

1935 LAKELAND DR
JACKSON MS
39216-5028
US

V. Phone/Fax

Practice location:
  • Phone: 601-718-2468
  • Fax: 601-718-2487
Mailing address:
  • Phone: 601-718-2468
  • Fax: 601-718-2487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: