Healthcare Provider Details

I. General information

NPI: 1932639887
Provider Name (Legal Business Name): CLINTON EASOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

1225 N STATE ST
JACKSON MS
39202-2064
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902085
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: