Provider Demographics
NPI:1457799199
Name:HATHORN, STEPHANIE ANNE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ANNE
Last Name:HATHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PARK CIRCLE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-7800
Mailing Address - Country:US
Mailing Address - Phone:601-664-0455
Mailing Address - Fax:601-664-1675
Practice Address - Street 1:5422 CLINTON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-3004
Practice Address - Country:US
Practice Address - Phone:601-724-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1947101YM0800X
MST0465106H00000X
MST0465A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health