Healthcare Provider Details

I. General information

NPI: 1124417761
Provider Name (Legal Business Name): CLINTON WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4778
  • Fax: 601-984-5420
Mailing address:
  • Phone: 601-815-4778
  • Fax: 601-984-5420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR886071
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: