Provider Demographics
NPI:1316234719
Name:JOHNSON, MARY FRANCES (AUD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:FRANCES
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:FRANCES
Other - Last Name:WILKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5160
Mailing Address - Fax:601-815-6985
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5160
Practice Address - Fax:601-815-6985
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA3585231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSA3585OtherSTATE LICENSE
MSA3585OtherSTATE LICENSE
MS302I645839Medicare PIN