Provider Demographics
NPI:1215472717
Name:GARDNER, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GARDNER
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 1:1032 STATE HWY 50 W
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773
Mailing Address - Country:US
Mailing Address - Phone:662-524-4347
Mailing Address - Fax:662-524-4364
Practice Address - Street 1:1660 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2048
Practice Address - Country:US
Practice Address - Phone:662-258-8147
Practice Address - Fax:662-258-8217
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health