Provider Demographics
NPI:1598076903
Name:PAYNE, NANETTA S (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANETTA
Middle Name:S
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 N STATE ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5755
Mailing Address - Country:US
Mailing Address - Phone:601-506-8735
Mailing Address - Fax:601-767-2747
Practice Address - Street 1:4005 N STATE ST
Practice Address - Street 2:SUITE N
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5755
Practice Address - Country:US
Practice Address - Phone:601-506-8735
Practice Address - Fax:601-767-2747
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS48841103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical