Healthcare Provider Details

I. General information

NPI: 1457733016
Provider Name (Legal Business Name): LAKESHA COLE DPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121B CRESTWOOD CV
CLINTON MS
39056-3562
US

IV. Provider business mailing address

PO BOX 983
CLINTON MS
39060-0983
US

V. Phone/Fax

Practice location:
  • Phone: 769-798-7615
  • Fax:
Mailing address:
  • Phone: 769-798-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1722
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: