Healthcare Provider Details

I. General information

NPI: 1003388968
Provider Name (Legal Business Name): MRS. TIFFANI RICCHELE MCKNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 601-362-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM8449
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-8449
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: