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General NPI Number Information
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NPI Number | 1104747120
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Entity Type | Individual
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Provider Name | IRA BURNETT
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Gender | Male
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Dates
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Enumeration Date | 07/24/2026
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Last Update Date | 07/24/2026
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Provider Practice Location Address
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Address Line | 875 MS-475
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City | PEARL
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State | MS
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Zip | 39208
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Country | US
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Telephone | 601-664-6000
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Fax |
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Provider Business Mailing Address
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Address Line | 5330 N STATE ST LOT 118
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City | JACKSON
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State | MS
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Zip | 39206-3458
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Country | US
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Telephone | 601-937-9774
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 011707001029
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License Number State | MS
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