Healthcare Provider Details

I. General information

NPI: 1417744046
Provider Name (Legal Business Name): JONATHAN DERICK DODDS APRN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 04/25/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 COUNTY ROAD 8200
RIENZI MS
38865-9302
US

IV. Provider business mailing address

38 COUNTY ROAD 8200
RIENZI MS
38865-9302
US

V. Phone/Fax

Practice location:
  • Phone: 662-808-4957
  • Fax:
Mailing address:
  • Phone: 662-808-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number907369
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: