Healthcare Provider Details

I. General information

NPI: 1265720791
Provider Name (Legal Business Name): JOEL DALE NUTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST STE 100
JACKSON MS
39202-2064
US

IV. Provider business mailing address

1225 N STATE ST STE 100
JACKSON MS
39202-2064
US

V. Phone/Fax

Practice location:
  • Phone: 769-268-6625
  • Fax:
Mailing address:
  • Phone: 769-268-6625
  • Fax: 769-268-6624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number23979
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: