Healthcare Provider Details

I. General information

NPI: 1790087393
Provider Name (Legal Business Name): JACKSON PSYCHIATRY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 06/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NORTHLAKE AVE
RIDGELAND MS
39157-1715
US

IV. Provider business mailing address

201 NORTHLAKE AVE
RIDGELAND MS
39157-1715
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-4696
  • Fax: 601-414-9486
Mailing address:
  • Phone: 601-366-4696
  • Fax: 601-414-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS W. BYRD
Title or Position: OWNER
Credential: MD
Phone: 601-366-4696