Healthcare Provider Details

I. General information

NPI: 1790237170
Provider Name (Legal Business Name): JERUSALEM OUTREACH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 MARSHALL ST
CHARLESTON MS
38921-9506
US

IV. Provider business mailing address

710 MARSHALL ST P.O. BOX 405
CHARLESTON MS
38921-9506
US

V. Phone/Fax

Practice location:
  • Phone: 662-625-6788
  • Fax: 662-625-6787
Mailing address:
  • Phone: 662-625-6788
  • Fax: 662-625-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: BESSIE L BROOKS
Title or Position: CEO/DIRECTOR
Credential:
Phone: 662-625-6788