Healthcare Provider Details

I. General information

NPI: 1295150175
Provider Name (Legal Business Name): NATHAN TYLER ROSS MHPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DR STE 4300
CLINTON MS
39056-5610
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2005
  • Fax: 601-496-9452
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number621124
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: