=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033146725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVA MAE HENDERSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 06/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-709-5150
-----------------------------------------------------
Fax | 601-709-5151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3437
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39207-3437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-5321
-----------------------------------------------------
Fax | 601-354-5159
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 10119
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------