Healthcare Provider Details

I. General information

NPI: 1962023812
Provider Name (Legal Business Name): KANDACE ROSS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KANDACE SHUNIKA SHAVERS

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 WOODBURY RD
JACKSON MS
39206-4830
US

IV. Provider business mailing address

528 WOODBURY RD
JACKSON MS
39206-4830
US

V. Phone/Fax

Practice location:
  • Phone: 601-278-7137
  • Fax:
Mailing address:
  • Phone: 601-278-7137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2581
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: