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General NPI Number Information
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NPI Number | 1396084786
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Entity Type | Individual
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Provider Name | JOHN STEPHEN SOUTHERN EDD
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Gender | Male
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Dates
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Enumeration Date | 02/06/2013
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Last Update Date | 04/11/2019
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Provider Practice Location Address
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Address Line | 106 SUGALOCH CV
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City | JACKSON
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State | MS
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Zip | 39211-3435
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Country | US
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Telephone | 618-762-0303
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Fax |
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Provider Business Mailing Address
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Address Line | 106 SUGALOCH CV
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City | JACKSON
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State | MS
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Zip | 39211-3435
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Country | US
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Telephone | 618-762-0303
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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 | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071009636
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | T0188
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0571
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 08559
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 003695
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License Number State | PA
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Taxonomy #6
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 30540
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License Number State | CA
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Taxonomy #7
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071.009636
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License Number State | IL
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