Healthcare Provider Details

I. General information

NPI: 1982496212
Provider Name (Legal Business Name): WILLIE STEPHAN VAN HEERDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 02/17/2026
Certification Date: 02/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N. STATE STREET
JACKSON MS
39216
US

IV. Provider business mailing address

1865 LAKELAND DR APT 108
JACKSON MS
39216-4960
US

V. Phone/Fax

Practice location:
  • Phone: 601-674-1000
  • Fax:
Mailing address:
  • Phone: 681-267-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT-5800
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: