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General NPI Number Information
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NPI Number | 1215375746
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Entity Type | Organization
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Legal Business Name | PAYNE BEHAVIORAL MEDICINE
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Dates
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Enumeration Date | 06/06/2013
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Last Update Date | 06/06/2013
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Provider Practice Location Address
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Address Line | 4005 N STATE ST STE N
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City | JACKSON
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State | MS
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Zip | 39206-5755
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Country | US
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Telephone | 601-506-8735
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Fax | 601-767-2747
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Provider Business Mailing Address
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Address Line | 4005 N STATE ST STE N
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City | JACKSON
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State | MS
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Zip | 39206-5755
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Country | US
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Telephone | 601-506-8735
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Fax | 601-767-2747
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Authorized Official
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Title or Position | FOUNDER/PRESIDENT
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Name | DR. NANETTA PAYNE
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Credential | PHD
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Telephone | 601-506-8735
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 48841
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License Number State | MS
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