Healthcare Provider Details

I. General information

NPI: 1982045118
Provider Name (Legal Business Name): JORDAN PHIFER GIBBS B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 NEW HOPE DR
CORINTH MS
38834-7458
US

IV. Provider business mailing address

PO BOX 839
CORINTH MS
38835-0839
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-7199
  • Fax: 662-286-8908
Mailing address:
  • Phone: 662-286-9883
  • Fax: 662-284-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: