Healthcare Provider Details

I. General information

NPI: 1306242458
Provider Name (Legal Business Name): PHILIP MASSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 09/11/2023
Certification Date: 09/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5345 HIGHWAY 18 W
JACKSON MS
39209-9421
US

IV. Provider business mailing address

PO BOX 2305
CLINTON MS
39060-2305
US

V. Phone/Fax

Practice location:
  • Phone: 601-927-0188
  • Fax: 601-292-7998
Mailing address:
  • Phone: 601-272-2202
  • Fax: 601-292-7998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM7217
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAD07-046M
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7217
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: