Healthcare Provider Details

I. General information

NPI: 1669842068
Provider Name (Legal Business Name): SHADA JAKES MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4780 I 55 N STE 105
JACKSON MS
39211-5542
US

IV. Provider business mailing address

PO BOX 1046
CLARKSDALE MS
38614-1046
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-4816
  • Fax: 601-956-4817
Mailing address:
  • Phone: 662-627-7267
  • Fax: 662-627-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: