Healthcare Provider Details

I. General information

NPI: 1780120071
Provider Name (Legal Business Name): STEPHANIE THOMAS PCMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 BRIARWOOD DR SUITE 510
JACKSON MS
39206-3051
US

IV. Provider business mailing address

460 BRIARWOOD DR SUITE 510
JACKSON MS
39206-3051
US

V. Phone/Fax

Practice location:
  • Phone: 601-956-4816
  • Fax: 601-956-4817
Mailing address:
  • Phone: 601-956-4816
  • Fax: 601-956-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2763
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: