Provider Demographics
NPI:1225606783
Name:STREETER, DANNY J
Entity Type:Individual
Prefix:MR
First Name:DANNY
Middle Name:J
Last Name:STREETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 I 55 N STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5542
Mailing Address - Country:US
Mailing Address - Phone:601-956-4816
Mailing Address - Fax:601-956-4817
Practice Address - Street 1:4780 I 55 N STE 105
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5542
Practice Address - Country:US
Practice Address - Phone:601-956-4816
Practice Address - Fax:601-956-4817
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01670076Medicaid