Healthcare Provider Details

I. General information

NPI: 1356919195
Provider Name (Legal Business Name): SHEA FOX HUTCHINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LAKELAND DR
JACKSON MS
39216-4829
US

IV. Provider business mailing address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-7784
  • Fax:
Mailing address:
  • Phone: 769-777-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC4728
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: