Healthcare Provider Details

I. General information

NPI: 1720383466
Provider Name (Legal Business Name): PAMELA COTTRELL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
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: 601-981-2016
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-981-2016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM7639
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberM7639
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: