Healthcare Provider Details

I. General information

NPI: 1386682102
Provider Name (Legal Business Name): ROSETTA WALKER HARRIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 E CAPITOL ST 840 TRUST MARK BLDG.
JACKSON MS
39201-2503
US

IV. Provider business mailing address

110 FREEDOM ST PO BOX 159
ITTA BENA MS
38941-2507
US

V. Phone/Fax

Practice location:
  • Phone: 800-632-6074
  • Fax: 866-341-7509
Mailing address:
  • Phone: 662-392-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC1817
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: