Healthcare Provider Details

I. General information

NPI: 1457799199
Provider Name (Legal Business Name): MRS. STEPHANIE ANNE HATHORN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5422 CLINTON BLVD
JACKSON MS
39209-3004
US

IV. Provider business mailing address

200 PARK CIRCLE DR STE 1
FLOWOOD MS
39232-7800
US

V. Phone/Fax

Practice location:
  • Phone: 601-724-5040
  • Fax:
Mailing address:
  • Phone: 601-664-0455
  • Fax: 601-664-1675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1947
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0465
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0465A
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: