Healthcare Provider Details

I. General information

NPI: 1467802140
Provider Name (Legal Business Name): ADRIAN VANBUREN-TRAVIS PCMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

IV. Provider business mailing address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2497
  • Fax: 601-321-2476
Mailing address:
  • Phone: 601-321-2497
  • Fax: 601-321-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3767
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: