Basic Information
| Provider Information | |||||||||
| NPI: | 1851730121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SONNY MONTGOMER VAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2013 | ||||||||
| LastUpdateDate: | 06/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | MICAH | ||||||||
| AuthorizedOfficialMiddleName: | DICKSON | ||||||||
| AuthorizedOfficialTitleorPosition: | OUTPATIENT LCSW | ||||||||
| AuthorizedOfficialTelephone: | 6013624471 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | C6323 | MS | Y | Hospitals | Special Hospital |
No ID Information.