Healthcare Provider Details

I. General information

NPI: 1871024489
Provider Name (Legal Business Name): JOHN SHAUGHNESSY III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1250
JACKSON MS
39216-4609
US

IV. Provider business mailing address

504 CLINTON CENTER DRIVE CBO - SUITE 4300
CLINTON MS
39056-5106
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax: 601-200-5939
Mailing address:
  • Phone: 601-815-2005
  • Fax: 601-984-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number33327
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number33327
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: