Healthcare Provider Details

I. General information

NPI: 1821120072
Provider Name (Legal Business Name): HEATHER ALICIA HANCOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

310 DOVER LN
MADISON MS
39110-9418
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5020
  • Fax: 601-984-5042
Mailing address:
  • Phone: 901-491-9952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number43457
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: