Healthcare Provider Details

I. General information

NPI: 1710072962
Provider Name (Legal Business Name): LUCILLE G COCKERHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON
JACKSON MS
39216-5199
US

IV. Provider business mailing address

454 FOREST AVE
JACKSON MS
39206
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-368-4409
Mailing address:
  • Phone: 601-362-4471
  • Fax: 601-368-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC1188
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: