Healthcare Provider Details

I. General information

NPI: 1346563137
Provider Name (Legal Business Name): DANNY RAY BURGESS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 E WOODROW WILSON AVE
JACKSON MS
39216-5112
US

IV. Provider business mailing address

1910 LAKELAND DR SUITE C
JACKSON MS
39216-5029
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-2611
  • Fax:
Mailing address:
  • Phone: 601-713-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number49854
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: