George Woodson Gully Jr., LPN

Key facts

NPI

1003579509

Entity type

Individual (NPI type 1)

Primary specialty

Licensed Practical Nurse 164W00000X

License

338464 (MS)

Practice address

1935 Lakeland Dr Ste 900
Jackson, MS 39216-5028

Phone

(601) 718-2468

NPI assigned

Oct 21, 2021

Sex

Male

Sole proprietor

No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Jackson Comprehension Treatment Center Addiction (Substance Use Disorder) Counselor · Jackson, MS · NPI 1003757675
  NPD (past)

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Practice roles

Specialties & licenses

Addresses

Electronic endpoints

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Oct 21, 2021.

{
    "created_epoch": "1634774400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1634774400000",
    "number": "1003579509",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1935 LAKELAND DR STE 900",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392165028",
            "telephone_number": "601-718-2468"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1935 LAKELAND DR STE 900",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392165028",
            "telephone_number": "601-718-2468"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GULLY",
        "first_name": "GEORGE",
        "middle_name": "WOODSON",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "LPN",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-10-21",
        "last_updated": "2021-10-21",
        "certification_date": "2021-10-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "164W00000X",
            "taxonomy_group": "",
            "desc": "Licensed Practical Nurse",
            "state": "MS",
            "license": "338464",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "Jackson",
            "affiliation": "N",
            "address_1": "1935 Lakeland Dr Ste 900",
            "city": "Jackson",
            "state": "MS",
            "country_code": "US",
            "postal_code": "392165028",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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All providers in Jackson, MS · Licensed Practical Nurse in Mississippi