Provider Demographics
NPI:1134135783
Name:HERZOG, JAMES DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVID
Last Name:HERZOG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 INTERSTATE 55 NORTH
Mailing Address - Street 2:SUITE 208
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5931
Mailing Address - Country:US
Mailing Address - Phone:601-981-5757
Mailing Address - Fax:601-981-5494
Practice Address - Street 1:4500 INTERSTATE 55 NORTH
Practice Address - Street 2:SUITE 208
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-981-5757
Practice Address - Fax:601-981-5494
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26348103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist