Healthcare Provider Details

I. General information

NPI: 1487564522
Provider Name (Legal Business Name): CARLY ELIZABETH JERGINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 BROOKMAN DR EXT
BROOKHAVEN MS
39601-2311
US

IV. Provider business mailing address

2706 HIGHWAY 583 SE
BOGUE CHITTO MS
39629-9634
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-2300
  • Fax:
Mailing address:
  • Phone: 601-823-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP-1619
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: