Healthcare Provider Details

I. General information

NPI: 1396084786
Provider Name (Legal Business Name): JOHN STEPHEN SOUTHERN EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DR. JOHN S SOUTHERN

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 SUGALOCH CV
JACKSON MS
39211-3435
US

IV. Provider business mailing address

106 SUGALOCH CV
JACKSON MS
39211-3435
US

V. Phone/Fax

Practice location:
  • Phone: 618-762-0303
  • Fax:
Mailing address:
  • Phone: 618-762-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071009636
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0188
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0571
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number08559
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number003695
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number30540
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.009636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: