Healthcare Provider Details

I. General information

NPI: 1346536158
Provider Name (Legal Business Name): RUTH DRAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 WILL O WOOD BLVD
JACKSON MS
39212-3556
US

IV. Provider business mailing address

4910 WILL O WOOD BLVD
JACKSON MS
39212-3556
US

V. Phone/Fax

Practice location:
  • Phone: 601-259-0346
  • Fax:
Mailing address:
  • Phone: 601-259-0346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC4549
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: