Provider Demographics
NPI:1275245797
Name:HIGGINS, JOHN (BS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HIGGINS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2305
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-2305
Mailing Address - Country:US
Mailing Address - Phone:601-927-0188
Mailing Address - Fax:
Practice Address - Street 1:5345 HIGHWAY 18 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-9421
Practice Address - Country:US
Practice Address - Phone:601-927-0188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02551264Medicaid