Healthcare Provider Details

I. General information

NPI: 1164785689
Provider Name (Legal Business Name): SHONTIA VASH'E MORRIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHONTIA VASH'E JACKSON

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N SUITE 220
JACKSON MS
39211-5930
US

IV. Provider business mailing address

5936 KRISTEN DR
JACKSON MS
39211-2835
US

V. Phone/Fax

Practice location:
  • Phone: 601-613-7569
  • Fax:
Mailing address:
  • Phone: 601-613-7569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1328
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number198544
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: