Healthcare Provider Details

I. General information

NPI: 1902392228
Provider Name (Legal Business Name): MONIQUE BUCKHAULTER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

IV. Provider business mailing address

3450 HIGHWAY 80 W
JACKSON MS
39209-7201
US

V. Phone/Fax

Practice location:
  • Phone: 601-321-2400
  • Fax: 601-985-5174
Mailing address:
  • Phone: 601-321-2400
  • Fax: 601-985-5174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP-0246
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: