Healthcare Provider Details

I. General information

NPI: 1861856841
Provider Name (Legal Business Name): LEE-KEETHIA TYANNE THOMPSON-PORTER CMHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
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

4780 I 55 N STE 105
JACKSON MS
39211-5542
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 NumberCMHT2942
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: