Healthcare Provider Details

I. General information

NPI: 1548771611
Provider Name (Legal Business Name): DANIEL BARNES PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 06/07/2022
Certification Date: 05/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E WOODROW WILSON DR 116A4
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax:
Mailing address:
  • Phone: 601-362-4471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number581010
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number581010
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: