Healthcare Provider Details

I. General information

NPI: 1881743326
Provider Name (Legal Business Name): DANNETTE SMITH JOHNSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET DEPARTMENT OF MEDICINE DIVISION OF RHEUMATOLOGY
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET JMM ROOM 2525
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5540
  • Fax:
Mailing address:
  • Phone: 601-984-6426
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberL9266
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number19808
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: