Healthcare Provider Details

I. General information

NPI: 1720476906
Provider Name (Legal Business Name): CHANGE YOUR WORLD MENTAL HEALTH AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4807 N STATE ST STE 401
JACKSON MS
39206-4826
US

IV. Provider business mailing address

4807 N STATE ST STE 401
JACKSON MS
39206-4826
US

V. Phone/Fax

Practice location:
  • Phone: 601-316-6163
  • Fax:
Mailing address:
  • Phone: 601-316-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHIRLEY DANIELS
Title or Position: OWNER
Credential:
Phone: 601-316-6163