Healthcare Provider Details

I. General information

NPI: 1073237665
Provider Name (Legal Business Name): TINA HODGES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 RAYMOND RD
JACKSON MS
39204-3802
US

IV. Provider business mailing address

500 NORTHPOINTE PKWY APT 113
JACKSON MS
39211-2395
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 601-559-9266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM10219
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: