Healthcare Provider Details

I. General information

NPI: 1730274887
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST WOODROW WILSON DRIVE
JACKSON MS
39216-5199
US

IV. Provider business mailing address

1500 EAST WOODROW WILSON DRIVE
JACKSON MS
39216-5199
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-368-4483
Mailing address:
  • Phone: 601-362-4471
  • Fax: 601-368-4483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR422643
License Number State

VIII. Authorized Official

Name: LAURIE SMITH
Title or Position: CLINICAL DIETITIAN
Credential: R.D. C.N.S.D.
Phone: 601-362-4471