=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417744046
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN DERICK DODDS APRN PMHNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2025
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 COUNTY ROAD 8200
-----------------------------------------------------
City | RIENZI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38865-9302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-808-4957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 COUNTY ROAD 8200
-----------------------------------------------------
City | RIENZI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38865-9302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-808-4957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 907369
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------