Healthcare Provider Details

I. General information

NPI: 1740712884
Provider Name (Legal Business Name): ASHLEY VILLARREAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1418 GREYMONT AVE APT B
JACKSON MS
39202-1803
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5532
  • Fax:
Mailing address:
  • Phone: 601-819-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28780
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28780
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: