Healthcare Provider Details

I. General information

NPI: 1780356212
Provider Name (Legal Business Name): CANTRELL OLLIE ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2021
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N STATE ST
JACKSON MS
39202-2064
US

IV. Provider business mailing address

PO BOX 2153 DEPT 1947
BIRMINGHAM AL
35287-0001
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1031
  • Fax:
Mailing address:
  • Phone: 901-226-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906306
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: