Healthcare Provider Details

I. General information

NPI: 1780308205
Provider Name (Legal Business Name): JERI PITTMAN PCCSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DEWEY ST
COLUMBIA MS
39429-2751
US

IV. Provider business mailing address

PO BOX 18679
HATTIESBURG MS
39404-8679
US

V. Phone/Fax

Practice location:
  • Phone: 601-736-6799
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3737
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: