Healthcare Provider Details

I. General information

NPI: 1912452095
Provider Name (Legal Business Name): RESTORE COUNSELING AND CONSULTING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N STE 223
JACKSON MS
39211-5931
US

IV. Provider business mailing address

4500 I 55 N STE 220
JACKSON MS
39211-5931
US

V. Phone/Fax

Practice location:
  • Phone: 601-214-7464
  • Fax: 601-398-9493
Mailing address:
  • Phone: 601-214-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMS

VIII. Authorized Official

Name: SHANDRA WILSON
Title or Position: OWNER
Credential: LPC
Phone: 601-214-7464