Healthcare Provider Details

I. General information

NPI: 1134135783
Provider Name (Legal Business Name): JAMES DAVID HERZOG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 INTERSTATE 55 NORTH SUITE 208
JACKSON MS
39211-5931
US

IV. Provider business mailing address

4500 INTERSTATE 55 NORTH SUITE 208
JACKSON MS
39211-5931
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-5757
  • Fax: 601-981-5494
Mailing address:
  • Phone: 601-981-5757
  • Fax: 601-981-5494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number26348
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: