Healthcare Provider Details

I. General information

NPI: 1861647489
Provider Name (Legal Business Name): ELIZABETH KEELING HENSLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH OATES KEELING M.D.

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 PETIT BOIS ST S
JACKSON MS
39211-6709
US

IV. Provider business mailing address

PO BOX 13708
JACKSON MS
39236-3708
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-0067
  • Fax:
Mailing address:
  • Phone: 601-981-0067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10776
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: