Basic Information
| Provider Information | |||||||||
| NPI: | 1821292046 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNKHOUSER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004749 | ||||||||
| FaxNumber: | 6012005929 | ||||||||
| Practice Location | |||||||||
| Address1: | 286 CALHOUN STATION PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012004321 | ||||||||
| FaxNumber: | 6018590159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R859048 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 02300532 | 05 | MS | MEDICAID | P00739236 | 01 | RAILROAD MEDICARE | OTHER |