=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407423809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BILLY WAYNE JEFFERSON JR. DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2021
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6051 U S HIGHWAY 49
-----------------------------------------------------
City | HATTIESBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39401-7200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-441-2975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 SWEET MAPLE TRL
-----------------------------------------------------
City | PETAL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39465-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-441-2975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 337599
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 32525
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------