Healthcare Provider Details

I. General information

NPI: 1578709713
Provider Name (Legal Business Name): HOLLOWAY PSYCHIATRIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742D MAGNOLIA ST
MADISON MS
39110-8903
US

IV. Provider business mailing address

742D MAGNOLIA ST
MADISON MS
39110-8903
US

V. Phone/Fax

Practice location:
  • Phone: 601-607-5107
  • Fax: 601-607-5109
Mailing address:
  • Phone: 601-607-5107
  • Fax: 601-607-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number16327
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number16327
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number16327
License Number StateMS

VIII. Authorized Official

Name: JENNIFER L HAMMOND
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-607-5107