Provider Demographics
NPI:1295771715
Name:HENDERSON, JOHN MICHAEL (MB, CHB, FRCS(ED), F)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MB, CHB, FRCS(ED), F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:SUITE H 132
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-815-4700
Mailing Address - Fax:601-815-5474
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-815-4700
Practice Address - Fax:601-815-5474
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063394H208600000X
MS23977208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0887296Medicaid
OHHE7353181Medicare PIN
OH0887296Medicaid