Provider Demographics
NPI:1922814284
Name:PUCKETT, JOHN DEAN (PLPC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DEAN
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 PINE LANE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4019
Mailing Address - Country:US
Mailing Address - Phone:601-573-2858
Mailing Address - Fax:
Practice Address - Street 1:3900 LAKELAND DR STE 203
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8853
Practice Address - Country:US
Practice Address - Phone:601-228-6907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-0725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health