Healthcare Provider Details

I. General information

NPI: 1902477920
Provider Name (Legal Business Name): DEMETRIA S WALLS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
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: 601-927-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM8329
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: