Healthcare Provider Details

I. General information

NPI: 1841010915
Provider Name (Legal Business Name): STACEY MATTHEWS OVERSTREET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 10/14/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 OLD SQUARE RD STE 101
JACKSON MS
39211-5533
US

IV. Provider business mailing address

580 S PEAR ORCHARD RD APT 1708
RIDGELAND MS
39157-4219
US

V. Phone/Fax

Practice location:
  • Phone: 601-977-9353
  • Fax:
Mailing address:
  • Phone: 601-842-0645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1214
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: