Healthcare Provider Details

I. General information

NPI: 1679111389
Provider Name (Legal Business Name): TAWNY RENEE WILLIAMS CSSMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 BRIARWOOD DR STE 302
JACKSON MS
39206-3033
US

IV. Provider business mailing address

409 BRIARWOOD DR STE 302
JACKSON MS
39206-3033
US

V. Phone/Fax

Practice location:
  • Phone: 769-572-4389
  • Fax: 769-572-4391
Mailing address:
  • Phone: 769-572-4389
  • Fax: 769-572-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: