Healthcare Provider Details

I. General information

NPI: 1548213887
Provider Name (Legal Business Name): CLINIC FOR WOMEN OF CENTRAL MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 HOSPITAL DR
JACKSON MS
39204-3410
US

IV. Provider business mailing address

1820 HOSPITAL DR
JACKSON MS
39204-3410
US

V. Phone/Fax

Practice location:
  • Phone: 601-372-1541
  • Fax: 601-373-5141
Mailing address:
  • Phone: 601-372-1541
  • Fax: 601-373-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number09597
License Number StateMS

VIII. Authorized Official

Name: MRS. ALICE FAY MABRY
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-372-1541