Healthcare Provider Details

I. General information

NPI: 1134704869
Provider Name (Legal Business Name): JUSTIN HARRIS HUTCHISON CMHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 MARQUETTE RD
BRANDON MS
39042-3038
US

IV. Provider business mailing address

PO BOX 88
BRANDON MS
39043-0088
US

V. Phone/Fax

Practice location:
  • Phone: 601-825-8800
  • Fax: 601-824-1681
Mailing address:
  • Phone: 601-824-0342
  • Fax: 601-824-1681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4443
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: