Healthcare Provider Details

I. General information

NPI: 1053639088
Provider Name (Legal Business Name): HART KATHERINE WYLIE PMHNP, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DR SUITE P-121
JACKSON MS
39216-4913
US

IV. Provider business mailing address

1855 LAKELAND DR SUITE P-121
JACKSON MS
39216-4913
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-4696
  • Fax:
Mailing address:
  • Phone: 601-366-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1360
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0434
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR883581
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: