Healthcare Provider Details

I. General information

NPI: 1073679817
Provider Name (Legal Business Name): COPAC ADDICTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 HIGHWAY 43 N
BRANDON MS
39047-7240
US

IV. Provider business mailing address

5857 KRISTEN DR
JACKSON MS
39211-2831
US

V. Phone/Fax

Practice location:
  • Phone: 601-829-2500
  • Fax: 601-829-4278
Mailing address:
  • Phone: 601-956-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberR586986
License Number StateMS

VIII. Authorized Official

Name: WANDA NEWTON JOHNSON
Title or Position: FAMILY NURSE PRACTITIONER
Credential: CFNP
Phone: 601-829-2500