Healthcare Provider Details

I. General information

NPI: 1760414494
Provider Name (Legal Business Name): CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 I 20 FRONTAGE RD
BOLTON MS
39041-9126
US

IV. Provider business mailing address

3502 W. NORTHSIDE DRIVE
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-866-2522
  • Fax:
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JASMIN CHAPMAN
Title or Position: CEO
Credential: DDS
Phone: 601-362-5321