Healthcare Provider Details

I. General information

NPI: 1033615919
Provider Name (Legal Business Name): KELLEN DAWSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2018
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 OLD CANTON RD
JACKSON MS
39216-4219
US

IV. Provider business mailing address

3120 OLD CANTON RD
JACKSON MS
39216-4219
US

V. Phone/Fax

Practice location:
  • Phone: 800-685-3772
  • Fax:
Mailing address:
  • Phone: 337-654-1478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number31541
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: