Healthcare Provider Details

I. General information

NPI: 1851219398
Provider Name (Legal Business Name): IMOGEN KIERAN NICHOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W STE R
CLINTON MS
39056-4108
US

IV. Provider business mailing address

7 TREEWAY DR
BRANDON MS
39042-2301
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax:
Mailing address:
  • Phone: 615-967-7726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: