Healthcare Provider Details

I. General information

NPI: 1295771715
Provider Name (Legal Business Name): JOHN MICHAEL HENDERSON MB, CHB, FRCS(ED), F
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N STATE ST SUITE H 132
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4700
  • Fax: 601-815-5474
Mailing address:
  • Phone: 601-815-4700
  • Fax: 601-815-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35063394H
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23977
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: