Healthcare Provider Details

I. General information

NPI: 1174881767
Provider Name (Legal Business Name): HEATH HERNDON SMYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 OLD CANTON RD
JACKSON MS
39211-2946
US

IV. Provider business mailing address

6250 OLD CANTON RD
JACKSON MS
39211-2946
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1000
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-968-1000
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: