=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790087393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKSON PSYCHIATRY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2010
-----------------------------------------------------
Last Update Date | 06/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 NORTHLAKE AVE
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-366-4696
-----------------------------------------------------
Fax | 601-414-9486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 NORTHLAKE AVE
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-366-4696
-----------------------------------------------------
Fax | 601-414-9486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DOUGLAS W. BYRD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-366-4696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TP0016X
-----------------------------------------------------
Taxonomy Name | Prescribing (Medical) Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------