Healthcare Provider Details

I. General information

NPI: 1912273228
Provider Name (Legal Business Name): THOMAS J PAYNE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE JACKSON MEDICAL MALL, STE ME-102
JACKSON MS
39213-7681
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE JACKSON MEDICAL MALL, STE ME-102
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-615-1180
  • Fax: 601-815-5986
Mailing address:
  • Phone: 601-615-1180
  • Fax: 601-815-5986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number28-386
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: