Healthcare Provider Details

I. General information

NPI: 1528610326
Provider Name (Legal Business Name): BENETRA MANGUM-JOHNSON PHD, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N. STATE ST. DEPT. OF PSYCHIATRY AND HUMAN BEHAVIOR (H808)
JACKSON MS
39216
US

IV. Provider business mailing address

2500 NORTH STATE STREET CBO - SUITE 4200
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-6337
  • Fax:
Mailing address:
  • Phone: 601-496-9794
  • Fax: 601-815-0434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7180
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: