Healthcare Provider Details

I. General information

NPI: 1376094532
Provider Name (Legal Business Name): JACKSON FAMILY FIRST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CEDARWOOD DR
JACKSON MS
39212-2208
US

IV. Provider business mailing address

125 CEDARWOOD DR
JACKSON MS
39212-2208
US

V. Phone/Fax

Practice location:
  • Phone: 601-503-4563
  • Fax:
Mailing address:
  • Phone: 601-503-4563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHANDA M. RHODES
Title or Position: OWNER
Credential:
Phone: 601-503-4563