Healthcare Provider Details

I. General information

NPI: 1275629487
Provider Name (Legal Business Name): KATHY LUPER WOODLIFF LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 CRANE RIDGE DR
JACKSON MS
39216-4944
US

IV. Provider business mailing address

1315 BELVOIR PL
JACKSON MS
39202-1208
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-8700
  • Fax:
Mailing address:
  • Phone: 601-969-1396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0503
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: