Healthcare Provider Details

I. General information

NPI: 1609804483
Provider Name (Legal Business Name): ALICE H EMANUEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 08/13/2007
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

PO BOX 12976
JACKSON MS
39236-2976
US

V. Phone/Fax

Practice location:
  • Phone: 800-632-6074
  • Fax: 866-341-7509
Mailing address:
  • Phone: 601-206-7770
  • Fax: 601-206-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC0368
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0368
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: